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http://www.archive.org/details/infectionsofhand1912kana 


Infections  of  thf.  Hand 


A  GUIDE  TO  THE  SURGICAL  TREATMENT  OF 

ACUTE  AND  CHRONIC  SUPPURATIVE 

PROCESSES  IN  THE  FINGERS, 

HAND,  AND  FOREARM 


BY 


ALLEN    B.  KANAVEL,  M.D. 

ASSISTANT     PROFESSOR     OF    SURGERY,     NORTHWESTERN     UNIVERSITY     MEDICAL    SCHOOL; 
ATTENDING  SURGEON,  WESLEY  AND   POST-GRADUATE  HOSPITALS,  CHICAGO 


TlllustrateD  witb  133  lEngravings 


-  •  V 


.,   ^  1^'    ■' 


LEA    &    FEBIGER 

PHILADELPHIA    AND     NEW    YORK 


Entered  according  to  Act  of  Congress,  in  the  year  1912,  by 

LEA   &    FEBIGER 

in  the  Office  of  the  Librarian  of  Congress.     All  rights  reserved 


^ir.€^- 


a. I 


PREFACE 


In  the  presentation  of  a  contribution  such  as  this, 
an  author  is  at  a  loss  to  know  just  how  much  of  the 
experimental  and  anatomical  investigations  upon  which 
his  surgical  deductions  are  based  should  be  included. 
Upon  one  hand  is  the  fear  that,  if  too  much  is  intro- 
duced, the  practical  surgical  deductions  will  be  lost  to 
the  busy  and  hurried  practitioner  who  first  sees  these 
cases;  upon  the  other,  if  dogmatic  statements  are  made 
as  to  diagnosis  and  therapy,  although  based  on  sound 
reas^oning  and  true  for  the  great  majority  of  cases,  the 
careful  surgeon  will  lack  the  basal  facts  upon  which  he 
can  diagnosticate  and  treat  the  atypical  and  hence 
more  dreaded  cases.  The  author  has,  therefore, 
attempted  so  to  arrange  the  results  of  his  experimental 
work  that,  although  all  of  the  facts  are  given  upon 
which  deductions  can  be  made  in  the  latter  cases,  the 
chapters  are  so  grouped  that  the  busy  practitioner  can 
find  the  part  dealing  with  his  particular  case  quickly. 

Given  a  case  in  which  the  practitioner  is  in  doubt, 
he  should  read  the  chapters  upon  "Diagnosis  and 
Treatment  in  General."  This  will  indicate  the  group 
into  which  his  case  falls,  and  will  also  direct  him  to  the 
proper  sections  of  the  book  where  cases  of  that  nature 
are  treated  more  in  detail. 

,  The  author  takes  this  opportunity  to  make  acknowl- 
edgment of  the  many  courtesies,  in  the  wa^^  of  per- 
mission to  study  cases,  which  have  been  received  from 


iv  PREFACE 

members  of  the  profession  at  large,  including  Dr.  Van 
Hook,  Dr.  Martin,  and  his  co-workers  in  the  Surgical 
Department  of  the  Northwestern  University  Medical 
School,  Drs.  Besley  and  Richter.  He  feels  a  particular 
obligation  to  the  Anatomical  Department,  its  various 
instructors  and  students,  who  have  been  of  great  assist- 
ance on  many  occasions. 

To  his  surgical  assistants,  Dr.  Cushway,  Dr.  Eustace, 
Dr.  Wolfer,  and  many  others  not  so  intimately  asso- 
ciated with  his  work,  he  wishes  to  express  his  appre- 
ciation of  their  help  in  the  care  and  study  of  the 
individual  cases. 

Surgery,  Gynecology,  and  Obstetrics  has  kindly  given 

permission  to  use    certain  plates    from   the   author's 

articles  published  in  that  journal. 

A.  B.  K. 

Chicago,  1912. 


CONTENTS 


CHAPTER  I 

INTRODUCTION— GENERAL  DISCUSSION— TYPES  OF 
INFECTIONS 

History 17 

Scope  and  Classification  of  Types  of  Infection 20 


PART  I 


SIMPLE  LOCALIZED  INFECTIONS  AND  ALLIED  MINOR 
CLINICAL  ENTITIES 


CHAPTER  II 

INFECTIONS  OF  THE  DISTAL  PHALANGES 

Felons 25 

Treatment        29 

Paronychia 31 

Treatment 33 

Subepithelial  Abscesses 37 

CHAPTER  III 

CARBUNCULAR  INFECTIONS 

Anatomical  Considerations  and  Pathogenesis 38 

Treatment 41 

Differential  Diagnosis 45 

Oidiomycosis 45 

Chronic  Staphylococcus  Processes 48 

CHAPTER  IV 

MISCELLANEOUS  ABSCESSES 

Collar-button  Abscess  (Shirt-stud  Abscess)  (Frog  Felon)        ....  52 

Treatment 54 

Localized  Abscesses  in  the  Thenar  and  Hypothenar  Spaces    ....  55 


vi  CONTENTS 


PART  II 


GRAVE  INFECTIONS— TENOSYNOVITIS,  FASCIAL  SPACE 

ABSCESSES,  LYMPHANGITIS,  AND  ALLIED 

CONDITIONS 


CHAPTER  V 

DIAGNOSIS  IN  GENERAL 

Lymphangitis 58 

Tenosynovitis 59 

Fascial  Space  Infection 63 

Diagnosis  of  Extensions  from  Various  Sites 68 

CHAPTER  VI 

GENERAL  PRINCIPLES  OF  TREATMENT 

Rest io 

Systemic  Use  of  Drugs 70 

Passive  Hyperemia 71 

Hot,  Moist  Dressings 72 

Prophylactic  Incisions 74 

Drainage  and  Treatment  of  Wound 75 

Stimulation  of  Excretion 77 


SECTION  I 

THE  ANATOMY  OF  THE  HAND  AND  FOREARM,  WITH  ESPECIAL 

CONSIDERATION  OF  ITS  RELATION  TO  INFECTIONS  OF 

THE  SYNOVIAL  SHEATHS  AND  FASCIAL  SPACES 


CHAPTER  VII 

METHODS  OF  STUDY  IN  GENERAL— A  STUDY  OF  SERIAL 

CROSS-SECTIONS  OF  THE  HAND,  WITH  PARTICULAR 

RELATION  TO  THE  FASCIAL  SPACES 

Methods  of  Study  in  General 80 

A  Study  of  Serial  Cross-sections,  with  Particular  Relation  to  the  Fascial 

Spaces 83 

Middle  Palmar  Space 90 

Thenar  Space 91 

Hypothenar  Space 95 

Discussion  of   the  Relation  of  the  Middle  Palmar  and  Thenar 

Spaces 96 

Recapitulation 99 


COXThWT.S  VII 


CHAPTER  VIII 

THE   TENDON    SHEATHS— A    DISCUSSION   OF    THEIR 

ANATOMICAL   DISTRIBUTION    AND   RELATIONS, 

WITH    SURGICAL    DEDUCTIONS 

Sheaths  ujjon  the  Flexor  Surface loi 

The   Sheaths   of    the   Tendons   of  the    Index,  Middle,  and  Ring 

Fingers 102 

The  Radial  Bursa  and  the  Sheath  of  the  Flexor  Longus  PoUicis     .  104 
The  Ulnar  Bursa  and  the  Sheath  of  the  Tendon  of  the  Little 

Finger 105 

The  Intercommunication  of  the  Sheaths 109 

Sheaths  upon  the  Dorsum 112 


CHAPTER  IX 

THE  RELATION  BETWEEN  THE  SYNOVIAL  SHEATHS  AND 

-       THE    FASCIAL   SPACES— A   STUDY   BY   EXPERIMENTAL 

INJECTION  OF  THE  OUTLINES,  BOUNDARIES,  AND 

DIVERTICULA   OF    THE   FASCIAL   SPACES,    AND 

THE   RELATION    OF   THESE   TO    THE 

SYNOVIAL  SHEATHS 

The  Relation  of  the  Tendon  Sheath  Rupture  to  the  Fascial  Spaces     .  117 

Injection  via  the  Tendon  Sheath  of  the  Middle  Finger   .      .      .      .  117 

Injection  via  the  Tendon  Sheath  of  the  Ring  Finger       .      .      .      .  118 

Injection  via  the  Tendon  Sheath  of  the  Little  Finger      ....  120 

Injection  via  the  Tendon  Sheath  of  the  Index  Finger     ....  124 

Injection  via  the  Tendon  Sheath  of  the  Flexor  Longus  PoUicis       .  125 
General   Deductions   as  to   the  Relation   of   Tendon   Sheaths   to 

Fascial  Spaces 126 

The  Normal  Boundaries  of  the  Fascial   Spaces  and  the  Position  of 

Secondary  Abscesses  in  Case  of  Extension  from  the  Spaces     .  127 

The  Middle  Palmar  Space 127 

Injection  via  the  Tendon  Sheath  of  the  Ring  Finger   ....  127 

Injection  through  the  Palmar  Fascia 128 

Injection  along  the  Lumbrical  Muscle  of  the  Ring  Finger  .      .  133 

Thenar  Space 133 

Injection  via  the  Tendon  Sheath  of  the  Index  Finger    .      .      .  134 

Injection  of  the  Thenar  Space  under  Forcible  Pressure       .      .  135 
Injection  Through  Palmar  Fascia  in  Attempt  to  Reach  the 

Thenar  Space 139 

Dorsal  Subcutaneous  Space 140 

Injection  between  the  First  and  Second  Metacarpals    .      .      .  140 

Injection  between  the  Second  and  Third  Metacarpals  .      .      .  141 

Dorsal  Subaponeurotic  Space 142 

Injection  under  Tendons  of  Dorsum 142 

Hypothenar  Space 143 

Resume  of  Preceding  Experiments  as  to  Boundaries,  Diverticula, 

and  Extensions  from  the  Fascial  Spaces 143 


Vlll  CONTENTS 

CHAPTER  X 

ANATOMY  OF  THE  FOREARM  IN  RELATION  TO  INFECTIONS 

Anatomy  in  General 149 

Serial  Cross-sections  of  the  Forearm 150 

Experimental  Injections  of  the  Fascial  Spaces  of  the  Forearm     .            .  154 

Injection  of  the  Radial  Bursa 155 

Injection  of  the  Ulnar  Bursa 156 

Injection  from  the  Middle  Palmar  Space 157 

Resume  of  Findings  by  Dissection  and  Experimental  Injection  .      .      .  159 


SECTION  II 


THE    SURGICAL    CONSIDERATIONS    OF    TENDON    SHEATH 

INFECTIONS  AND  FASCIAL  SPACE  ABSCESSES  OF 

THE  HAND  AND  FOREARM 


CHAPTER  XI 

PATHOGENESIS— SOURCE  OF  INVOLVEMENT  OF  THE 
TENDON  SHEATHS  AND  FASCIAL  SPACES 

Etiology  in  General 163 

Source  of  Involvement  of  the  Various  Sheaths 164 

Extension  from  One  Sheath  to  Another 165 

Source  of  Involvement  of  the  Important  Fascial  Spaces  in  the  Hand    .  168 

Involvement  from  the  Tendon  Sheaths       .      . 168 

Direct  Implantation  of  the  Infection  in  the  Spaces    .....  169 

Involvement  by  Lymphatic  Extension 173 

Recapitulation    as    to    Source    of     Involvement    of    the    Fascial 

Spaces 176 

Extension  from  One  Fascial  Space  to  Another 177 


CHAPTER  XII 

THE  SPREAD  OF  INFECTION  FROM  ANY  GIVEN  PRIMARY 

FOCUS 


The  Probable  Extensions  from  Primary  Foci  on  the  Fingers 
The  Spread  of  Infection  Involving  the  Index  Finger 
The  Spread  of  Infection  Involving  the  Thumb     . 
The  Spread  of  Infection  Involving  the  Middle  Finger 
The  Spread  of  Infection  Involving  the  Ring  Finger  . 
Infection  Spreading  from  the  Little  Finger 
Infections  beginning  in  the  Palm  and  Dorsum 


185 
185 
191 
191 
192 

193 
194 


CONTENTS  IX 


CHAPTER  XIII 

THE  PATHOLOGY  OF  TENDON  SHEATH  AND  FASCIAL  SPACE 

ABSCESSES 

The  Tendon  Sheath  Proper 196 

The  Fascial  Space  Abscesses 198 


CHAPTER  XIV 

THE  SYMPTOMS,  SIGNS,  AND  DIAGNOSIS  OF  TENOSYNOVITIS 
AND  FASCIAL  SPACE  ABSCESSES 

The    Symptoms,    Signs,    and    Diagnosis    of    Acute    Tenosynovitis    in 

General 201 

Symptoms,   Signs,  and  Diagnosis  of  Extensions  from   Infections 

Beginning  in  the  Little  Finger 204 

Extension  to  Ulnar  Bursa 204 

Extension  to  Radial  Bursa 207 

Extension  to  Forearm 207 

Extension  to  Lumbrical  and  Palmar  Spaces 208 

Symptoms,   Signs,  and  Diagnosis  of  Extensions  from   Infections 

beginning  in  the  Index,  Middle,  and  Ring  Fingers       ....  209 
Symptoms,   Signs,  and  Diagnosis  of  Extensions  from   Infections 

beginning  in  the  Radial  Bursa 213 

The  Symptoms,  Signs,  and  Diagnosis  of  Fascial  Space  Abscesses      .      .  215 

The  IMiddle  Palmar  and  Thenar  Spaces 216 

The  Hypothenar  Space 223 

The  Dorsal  Abscesses 223 

Forearm  Abscesses 224 

Differential  Diagnosis 225 


CHAPTER  XV 

THE  TREATMENT  OF  ACUTE  SUPPURATIVE  TENOSYNOVITIS 

—GENERAL   CONSIDERATIONS— A   REVIEW   OF   THE 

LITERATURE 

Excerpts  from  the  Literature 228 


CHAPTER  XVI 

THE  TREATMENT  OF  ACUTE  SUPPURATIVE  TENOSYNOVITIS 
(Continued)— DISCUSSION  OF  TECHNIQUE 

Treatment  While  the  Diagnosis  May  be  in  Doubt 248 

Technique  of  Treatment  after  Diagnosis  is  Made 249 

Treatment   of    Tenosynovitis   of    the    Index,    Middle,    and   Ring 

Fingers 251 

When  the  Involvement  of  Adjacent  Areas  has  Begun       .      .  253 

The  Index  Finger 253 

The  Middle  Finger 255 

The  Ring  Finger 255 


X  CONTENTS 

Technique  of  Treatment  of  Tenosynovitis  of  flie   Little  Finger  and 

Ulnar  Bursa 255 

Treatment   of   Extensions   from    the   Little   Finger   and   the 

Ulnar  Bursa 262 

Treatment  of  Inflammation  of  the  Tendon  Sheath  of  the  Long 

Flexor  of  the  Thumb 265 

Treatment  of   Inflammation  of  the  Synovial  Sheaths  upon   the 

Dorsum 276 

After-treatment 276 


CHAPTER  XVII 

THE  TREATMENT  OF  FASCIAL  SPACE  ABSCESSES 

Technique  of  Treatment  of  Abscesses  in  the  Middle  Palmar  Space  .      .  282 
The  Treatment  of  Combined  Involvement  of  the  Middle  Palmar 

and  Thenar  Spaces 285 

The  Treatment  of  Combined  Involvement  of  the  Middle  Palmar 

and  Subaponeurotic  Spaces 289 

Technique  of  Treatment  of  Abscesses  in  the  Thenar  Space    ....  293 

Technique  of  Treatment  of  Abscesses  of  the  Subaponeurotic  vSpace      .      .  295 

After-treatment  in  Fascial  Space  Abscesses 296 

CHAPTER  XVIII 

PROGNOSIS    AND    RESUME    OF    ACUTE    SUPPURATIVE    TENO- 
SYNOVITIS AND  FASCIAL  SPACE  ABSCESSES 

Prognosis 297 

Resume 298 


SECTION  III 

LYMPHATIC  INFECTIONS 

CHAPTER  XIX 

THE  RELATION  OF  LYMPHANGITIS  TO  OTHER  TYPES  OF 
INFECTION— DISCUSSION  OF  THE  ANATOMY 

The  Relation  of  Lymphangitis  to  Other  Types  of  Infection     .      .      .  301 

Anatomy 302 

The  Lymphatic  Vessels  of  the  Hand  and  Forearm 304 

Superficial  Lymphatics 304 

Deep  Lymphatics , 312 


cox  T /'J  NTS  XI 


CHAFrilR  XX 

LYMPHANGITIS  -ETIOLOdY,   I'ATI  I()('.i':NESIS,  AND 
PATHOLOOY 

Predisposing  and  Active  Factors  in  the  Production  of  Lynipiiangitis  314 

Influence  of  Type  of  Germ 316 

Influence  of  the  Anatomy  on  the  Course 318 

Sporotrichosis 322 

Relation  of  Lymphatic  Abscesses  vStudied  Ijy  lixpcrinicnlal  Injections  .  323 

Report    of    Injections    of    Forearm    Near   tlic    Radial    and    Ulnar 

Vessels 323 

Experiments  by  Injection  along  Ulnar  Artery 325 

Pathology  of  Lymphangitis 325 

CHAPTER  XXI 

SYMPTOMS  AND  SIGNS  OF  LYMPHANGITIS 

Symptoms  and  Signs  in  General 328 

Types 329 

Type  I.   Simple  Acute  Lymphangitis 329 

Type  II.  Acute  Lymphangitis  with  Minor  Local  Complications      .  329 
Type    III.    Acute    Lymphangitis   with    Serious    Local   Complica- 
tions   329 

Type  IV.  Acute  Lymphangitis  with  Systemic  Involvement       .      .  329 

Acute  Lymphangitis  with  Serious  Local  Complications 330 

Phlegmonous  Lymphangitis 332 

Frequency  of  Localization  in  Lymphatic  Infections 333 

Acute  Lymphangitis  with  Systemic  Involvement t,t,t, 

Deep  Lymphangitis 334 

Systemic  Involv  ment 337 

Postmortem  Statistics 344 

Thrombophlebitis 345 

CHAPTER  XX IT 

PROGNOSIS  IN  LYMPHATIC  INFECTIONS 

CHAPTER  XX II I 

THE  TREATMENT  OF  LYAH^HATIC   INFECTIONS     (^I'MvRAU 

DISCUSSION 

Discussion  of  Various  Procedures 351 

Local 351 

Hot,  Moist  Dressings 351 


Rest 


353 


The  Bier  Treatment 353 

Incisions 354 

Systemic  Treatment 356 

Antagonistic  Drugs 356 

Serum  and  Vaccine  Treatment 357 

Supportive  Measures 356 


xu  V  CONTENTS 


CHAPTER  XXIV 

THE  TREATMENT  OF  THE  COMPLICATIONS  OF 
LYMPHANGITIS 

Tenosynovitis 359 

Subcutaneous  Abscesses 361 

Periglandular  Abscesses ' 362 

Subclavicular  and  Shoulder  Abscesses 362 

Systemic  Complications 363 

Chronic  Infections — Repeated  Infections 363 


SECTION  IV 

ALLIED   INFECTIONS 
CHAPTER  XXV 


ERYSIPELAS,  ERYSIPELOID,  GAS  BACILLUS  INFECTION, 
ANTHRAX 

Erysipelas 333 

Erysipeloid 373 

Gas  Bacillus  Infection 375 

Anthrax 379 


SECTION  V 

COMPLICATIONS  AND  SEQUELS  OF  INFECTIONS  OF  THE  HAND 

CHAPTER  XXVI 

FOREARM  INVOLVEMENT  FROM  INFECTIONS  OF  THE 
HAND— PATHOLOGY  AND  DIAGNOSIS 

Subcutaneous  Abscesses .  383 

Deep  Abscesses 384 

Forearm  Involvement — Abscess  Formation  without   Other   Complica- 
tion     *' 385 

Location  of  the  Abscesses 385 

Symptoms,  Signs,  and  Diagnosis 389 

Deep  Forearm  Involvement  Associated  with  Wrist-joint   Invasion     .  391 

Examination  of  the  Radial  Bursa  in  Cadavers 392 

Pathology  Found  in  Serious  Wrist-joint  Involvement       .      .      .  393 

Forearm  Involvement  with  Secondary  Hemorrhage 400 


CONTENTS  xiii 


CHAPTER  XXVII 

TREATMENT  OF  INVOLVEMENT  OF  THE  FOREARM 
SECONDARY  TO  HAND  INFECTIONS 

Treatment  of  Uncomplicated  Cases 405 

Treatment  in  Cases  Where  the  Wrist-joint  is  Involved 410 

Treatment  in  Cases  of  Secondary  Hemorrhage 413 


CHAPTER  XXVIII 

SEQUELS    OF    INFECTIONS    OF    THE    HAND— CHRONIC    PRO- 
CESSES,   OSTEOMYELITIS,    ARTHRITIS,    CONTRACTURES, 
AND  ATROPHY— RESUME,   CHRONIC   INFECTIONS 

Involvement  of  the  Finger  Proper 415 

Pathology 415 

Treatment 421 

Involvement  of  the  Hand  Proper  and  the  Metacarpals  and  Carpals      .  426 

Pathology 426 

Treatment         ...  * 433 

Atrophy  and  Contracture 436 

Resume — Chronic  Infections 437 


INFECTIONS    OF    THE    HAND 


CHAPTER    I 

INTRODUCTION 

SCOPE  AND  CLASSIFICATION  OF  TYPES  OF  INFECTIONS 

The  accompanying  contribution  to  our  knowledge 
of  infections  of  the  hand  is  the  result  of  several  years' 
study,  comprising  experimental  and  anatomical  inves- 
tigations carried  on  in  conjunction  with  careful  clinical 
observation  of  an  extensive  number  of  cases.  In  the 
following  pages  the  diagnostic  factors  and  incisions 
which  this  work  has  suggested  wdll  be  described.  By 
their  use  it  has  been  possible  even  in  neglected  cases 
to  insure  a  restoration  to  complete  function  in  95  per 
cent,  of  the  abscesses  of  the  fascial  spaces;  while  in 
tendon-sheath  infections  the  morbidity  has  been 
reduced  by  fully  one-half,  and  a  greater  reduction  is 
possible  if  the  profession  as  a  whole  will  learn  to  make 
an  early  diagnosis  in  this  most  lamentable  compli- 
cation. 

HISTORY 

Professor  Albert^  says  that  while  the  word  pana- 
ritium was  not  used  by  Celsus,  it  is  found  in  the 
Arabian  and  other  ancient  writings,  and  appears  to 
be  a  corruption  of  the  Greek  -aoo'jycd  {-and  Ipyj^). 
Paracelsus,  Dorneus,  and  others  have  used  the  words 

'  Chir.,   1S85.  ii. 


18  INTRODUCTION 

pandalitium,  passa,  panaris,  and  panarium,  and  it 
cannot  be  said  whether  these  refer  to  different  types 
or  are  corruptions  of  the  same  word.  Concerning  the 
elemental  meaning  of  panaritium,  Forestus^  states: 
"Panaritium  s.  Paronychia  tumor  edicitur,  calidus, 
ulcerosus,  summe  dolorosus,  accidens  in  summitate 
digitorum  in  latere  unguis  et;  quandoque  tam  vehe- 
menter  aificiens,  ut  vigilias  et  inquietudinem  excitet." 

Our  anatomical  knowledge  of  the  lymphatic  vessels 
dates  back  to  the  time  of  Aristotle,  but  it  is  to 
Herophilus  (300  B.C.)  and  Herasistratus  (280  B.C.) 
to  whom,  according  to  Galenic  writings,  we  ought  to 
attribute  the  discovery  of  the  chyliferous  vessels. 
These  observations  fell  into  obscurity,  and  it  was  not 
until  1532,  when  Nicolas  Massa  discovered  renal 
lymphatics,  that  the  knowledge  of  the  subject  began 
to  grow.  Following  Eustachius,  Aselli,  and  others, 
Vessling  and  Rudbeck  in  the  seventeenth  century 
described  lymphatics  in  the  liver,  pancreas,  lungs, 
and  pelvis.  Mascagni,  Lippi,  and  Lauth  followed 
with  admirable  work,  while  Sappey,  in  1876,  published 
his  large  atlas  after  twenty  years  of  work,  when  the 
subject  can  be  said  to  have  been  put  upon  a  scientific 
basis. 

It  was  shortly  before  this  time,  however,  that  the 
study  of  lymphatic  abscesses  was  begun.  Bauchet's^ 
treatise,  in  1859,  upon  infections  of  the  hand  lacked 
this  knowledge  to  make  it  a  masterpiece.  From  this 
time  until  the  culmination  of  Sappey's  work  an  acri- 
monious discussion  was  maintained  over  the  subject 
of  lymphatic  versus  synovial  sheath  extension  of  infec- 
tion. Gosselin,  following  dissections,  adduced  proof 
that  extension  nearly  always  progressed  along  synovial 
sheaths.      Dolbeau    meanwhile   presented    a   masterly 

^  Chir.,  lib.  v,  Observat.  i6. 
"^  Du  Panaris,  Paris,  1859. 


IIISTOli)'  19 

discussion,  suijporlcd  by  clinical  evidence,  in  support 
of  the  possibility  of  lymphatic  extension  with  the 
formation  of  deep  abscesses.  Chevalet,'  a  pupil  of 
Dolbeau,  chose  for  his  doctorate  thesis,  in  1875,  to 
make  a  further  contribution  to  the  literature  in  sup- 
port of  his  master's  assumptions,  bringing  to  his  aid  the 
brilliant  investigations  of  Sappey  and  others.  Later, 
Polaillon  and  Le  Dentu  supported  the  theories  of 
Gosselin,  although  the  latter  was  led  to  admit  that  the 
theories  of  Dolbeau  might  have  some  justification  in 
a  few  cases.  Since  that  time  the  subject  has  received 
little  attention,  but  we  have  gradually  come  to  assume 
that  each  party  was  too  radical  in  its  claims  and  that 
infection  can  spread  by  either  channel,  an  assumption 
that  every  clinician  has  had  occasion  to  verify. 

In  later  3^ears  a  carefully  observed  series  of  cases 
has  been  reported  from  the  Griefswald  Clinic  by  Max 
Tornier,-  who  brought  prominently  before  the  pro- 
fession Helferich's  method  of  opening  widely  the 
sheaths,  which  was  later  substantiated  and  discussed 
with  carefully  observed  cases  by  Forssell.'^ 

I  wish  to  make  acknowledgment  of  abstracts  which 
I  have  taken  freely  from  these  authors.  Forssell  par- 
ticularly has  wTitten  a  most  masterly  article  upon 
tenosynovitis.  I  am  forced,  however,  to  take  issue 
with  him  as  to  certain  methods  of  treatment.  Concern- 
ing these  and  the  various  modern  ideas  as  to  the  treat- 
ment of  tenosynovitis,  full  reference  will  be  found  in 
the  chapter  dealing  w4th  that  subject. 

In  spite  of  the  fact  that  from  earliest  times  the 
importance  of  the  subject  has  been  recognized,  neither 

1  These  pour  le  doctorat  en  Medecine,  Paris,  1875. 

2  Beitrag  zur  Kenntnis  schwerer  Phlegmonen.  Inaugural  Dissertation, 
Griefswald,  1891. 

3  Klinische  Beitrage  zur  Kenntnis  dor  akut  septischen  Eiterungen  der 
Sehnenscheiden  der  Hohlhand  besonders  mit  Rticksicht  auf  die  Therapie, 
Nordisches  Medizinisches  Archiv,  1903.  Abt.  i.  Heft  3. 


20  INTRODUCTION 

in  text-books  nor  in  special  articles  can  the  student 
find  clear  descriptions  of  the  various  types  of  acute 
infections,  with  the  methods  of  their  diagnosis  and 
treatment.     This  I  shall  here  attempt  to  give. 

SCOPE  AND  CLASSIFICATION  OF  TYPES 

It  is  manifest  that  if  we  are  to  have  a  clear  idea  of 
the  various  phases  of  infections  of  the  hand,  it  will  be 
necessary  to  divide  the  subject  into  various  types, 
depending  upon  the  nature  of  the  infection  and  the 
results  it  produces.  It  should  be  understood  that  we 
are  dealing  with  acute  infective  processes,  and  not 
those  associated  with  syphilis,  tuberculosis,  and  other 
chronic  infections,  although  the  general  principles  laid 
down  by  the  anatomical  and  experimental  researches 
will  be  found  to  be  applicable  there  also. 

I  have  divided  the  subject  in  general  as  follows: 

1.  Simple  localized  infections  and  allied  minor 
clinical  entities. 

2.  Grave  infections. 

(a)  Discussion   of  diagnosis   and   treatment   in 

general. 

(b)  Tenosynovitis  and  fascial  space  abscesses. 

(c)  Acute  lymphangitis  and  allied  infections. 

(d)  Complications  and  sequelae  of  acute  infec- 

tions. 
It  is  true  that  in  certain  cases  we  shall  find  all  three 
of  the  graver  types  present — i.  e.,  sl  lymphangitis, 
a  tenosynovitis,  and  a  fascial  space  abscess — yet  in  a 
majority  of  cases  only  one  type  will  be  found.  If 
they  are  combined,  the  symptoms  and  signs  of  each 
are  present,  and  each  will  demand  a  separate  and 
distinct  form  of  treatment,  for  in  opening  a  synovial 
sheath  infection  we  do  not  by  any  means  drain  the 
fascial  spaces,  nor  vice  versa.     Again,  unless  we  have 


SCOPE  AND  CLASSIl'ICATION  OF  TVPES  21 

a  clear  picture  in  our  minds  of  fascial  space  infecticjn, 
and  in  a  given  case  do  not  determine  whether  or  not 
it  is  present  in  an  acute  tenosynovitis — and  the  diag- 
nosis is  by  no  means  easy— we  might  so  make  our 
incision  in  the  synovial  sheath  that  the  fascial  spaces 
would  become  infected  unnecessarily;  and  in  a  patient 
who  depends  upon  his  hands  for  his  livelihood,  such 
an  error  becomes  criminal  carelessness. 

Again,  while  a  lymphangitis  may  become  a  tenosyno- 
vitis or  fascial  space  infection,  in  a  great  majority  of 
cases  it  remains  a  clinical  and  pathological  entity, 
and  the  mistake  frequently  made  of  assuming  this 
relationship  and  treating  it  accordingly  has  been 
responsible  for  the  gravest  errors  and  most  serious 
consequences,  both  as  to  morbidity  and  mortality, 
that  I  have  met  in  my  experience. 

In  a  great  majority  of  cases  the  differentiation  of 
these  types  can  be  made,  but  I  know  of  no  single  rule 
by  which  it  can  be  done.  The  requisite  knowledge 
comes  only  with  a  clear  understanding  of  the  basic 
principles  of  inflammation  produced  by  the  various 
bacteria,  coupled  with  a  knowledge  of  the  anatomical 
relations  peculiar  to  the  hand  and  a  study  of  the 
course  any  given  infection  will  normally  pursue.  It 
has,  therefore,  seemed  necessary  to  give  in  some  detail 
the  anatomical  and  experimental  investigations  upon 
which  my  deductions  are  based,  rather  than  to  state 
dogmatically  the  rules  upon  which  a  diagnosis  should 
be  made  and  the  various  incisions  which  I  have  found 
to  lead  to  the  most  rapid  recovery.  If  one  will  take 
the  time  to  fix  in  mind  the  fundamental  facts  which 
are  here  discussed,  he  will  have  no  dif^culty  in  apply- 
ing them  to  any  given  case.  The  technical  procedures 
incident  to  the  operations  are  easily  learned  and 
applied.     In  almost  all  cases  the  difificulty  has  been  an 


22  INTRODUCTION 

improper  diagnosis,  both  as  to  the  nature  of  the  infec- 
tion and  the  position  of  the  pus. 

Therefore,  I  wish  to  emphasize  that  while  for  the 
sake  of  clearness  a  brief  resume  of  the  contents  has  been 
introduced  into  certain  chapters,  the  careful  surgeon 
will  find  it  necessary  to  read  the  context  for  the 
coordination  of  the  various  data. 

It  will  be  found  that  lymphatic  infections  follow  a 
distinct  anatomical  and  clinical  course,  having  at  all 
times  the  possibility  of  producing  certain  definite  com- 
plications which  may  be  prognosticated  and  antici- 
pated. We  shall  see  that  the  tendon  sheath  infections 
pursue  definite  lines  of  invasion,  and  the  position  of 
the  pockets  of  pus  when  rupture  occurs  can  be  prog- 
nosticated, so  that  incisions  can  be  made  early  at  these 
sites  and  further  extensions  prevented. 

Concerning  the  fascial  spaces  it  will  be  shown  that: 

(a)  There  are  certain  well-defined,  uniform  spaces 
upon  the  fingers,  palm,  and  dorsum  of  the  hand  in 
which  pus  can  accumulate. 

(b)  There  are  definite  anatomical  channels  by  which 
infection  arising  in  a  given  spot  will  extend  to  certain 
of  these  spaces,  while  certain  other  spaces  will  remain 
uninvolved;  hence  the  diagnosis  of  the  position  of  the 
pus  is  simplified  and  the  proper  site  for  the  incision 
determined. 

(c)  There  are  definite  anatomical  channels  by  which 
pus  can  spread  from  the  uniform  spaces  mentioned, 
and  when  this  occurs,  the  position  of  the  pus  can  be 
prognosticated. 

(d)  The  boundaries  of  the  fascial  spaces  having  been 
determined,  it  is  easily  seen  that  in  the  case  of  some 
of  these  the  incisions  for  evacuation  must  be  made  at 
definite  spots;  otherwise  important  structures  may  be 
injured,  or  by  ill-advised  incisions  adjacent  spaces  may 
be  opened  at  the  same  time  and  a  spread  of  the  infec- 


RCOI'E  AND  CI.ISSIIIC.iriON  Ol-    DI'l-.S  SA 

Lion  favcji'L'd  to  parts  ol  I  he  hand  that  would  not  have 
become  involved  without  this  unfortunate  surgical 
procedure. 

{e)  It  can  be  understood  readily  why,  in  certain  cases, 
the  infection  has  persisted  for  weeks  and  months  after 
apparently  opening  the  pus  pocket,  since  diverticula 
and  intermediary  chambers  have  not  been  taken  into 
consideration. 

The  inter-relation  of  these  various  facts  will  be 
emphasized  by  case  reports,  each  of  which  has  been 
introduced  to  illustrate  or  clarify  some  important 
clinical  fact.  The  number  could  have  been  multi- 
plied many  times,  but  I  have  tried  not  to  duplicate 
these  illustrations. 

We  will  return  now  to  the  slighter  infections,  such 
as  felons,  carbuncles,  paronychia,  etc.,  which  bear 
little  or  no  relation  to  these  more  serious  types  just 
considered.  It  must  be  remembered  that  they  are 
clinical  entities,  each  having  a  pathology  peculiar  to 
itself.  Owing  to  their  frequency  they  are  of  especial 
interest  to  the  practitioner.  While  the  diagnosis  is 
easily  made,  the  course  is  often  unnecessarily  pro- 
longed, owing  to  a  lack  of  appreciation  of  the  patho- 
logical anatomy  and  the  proper  means  of  treatment. 
These  types  will  be  discussed  in  the  immediately 
succeeding  chapters,  so  that  they  may  not  be  left  to 
confuse  the  student  later  while  studying  the  graver 
and  more  important  forms. 


PART    I 

SIMPLE    LOCALIZED     INFECTIONS    AND 
ALLIED  MINOR  CLINICAL  ENTITIES 


CHAPTER    I  I 

INFECTIONS   OF    THE    DISTAL    PHALANGES 

FELONS,  PARONYCHIA,  SUBEPITHELIAL  ABSCESSES 

FELONS 

Felons  are  among  the  most  common  infections  of 
the  distal  phalanx.  The  source  may  be  a  small  pin 
prick  or  unnoticed  injury,  and  occasionally  no  history 
of  injury  may  be  elicited.  The  patient  first  notices  a 
sticking  pain  in  the  distal  phalanx,  which  rapidly 
becomes  throbbing  in  character  and  most  severe.  He 
cannot  rest  or  sleep.  The  distal  portion  of  the  finger 
becomes  red  and  swollen.  Early  it  is  tender  to  the 
touch  and  this  tenderness  is  most  marked  o\'er  the 
site  of  the  infection.  In  the  later  stages,  after  pus 
formation  and  tissue  destruction,  the  sensitiveness 
disappears.  The  phalanx  is  at  first  tense  from  the 
edema;  more  tense,  in  fact,  than  is  ordinarily  observed 
with  edema,  owing  to  the  peculiar  anatomical  structure, 
which  will  be  discussed  later.  Soon  the  tenseness  is 
replaced  by  an  induration  and  later  by  a  fluctuating 
boggy  mass. 

The  reason  for  the  peculiar  pathological  condition 
which    is    present     here     in     localized     infection     and 


26  INFECTIONS  OF  THE  DISTAL  PHALANGES 

nowhere  else  in  the  body  is  worthy  of  consideration. 
The  ordinary  conception  of  the  pathogenesis  is  that 
which  has  been  attributed  to  Roux,  whether  justly  or 
not  I  cannot  say.  By  this  the  lymphatic  vessels  are 
supposed  to  run  perpendicularly  from  the  skin  to  the 
periosteum;  infection  takes  place  under  the  periosteum, 
which  is  lifted  off,  and  necrosis  of  the  bone  ensues. 
Against  this  assumption  we  have  the  very  firm  attach- 
ment of  the  periosteum  to  the  bone,  Sharpey's  fibers 
going  down  into  the  osseous  tissue  in  such  a  way  that 
it  is  practically  impossible  for  the  periosteum  to  be 
separated  and  differentiated  as  it  is  elsewhere.  More- 
over, there  are  certain  anatomical  peculiarities  which 
seem  to  point  to  another  explanation  of  this  frequent 
change,  so  essentially  different  from  that  noted  else- 
where in  the  body.  The  connective-tissue  framework 
is  such  as  to  produce  a  closed  sac  comprising  the  distal 
part  of  the  phalanx,  thus  differing  from  the  remainder 
of  the  finger,  while  the  glands  lying  in  the  columns 
of  fat  present  a  portal  for  the  entrance  of  pathogenic 
bacteria.  This  will  be  seen  by  examining  the  accom- 
panying cross  and  longitudinal  sections  of  the  phalanx. 
Some  of  the  glands  may  be  seen  lying  near  the  peri- 
osteum. Of  especial  interest  is  the  presence  of  the 
bloodvessels  which  may  be  seen  in  the  cross-section, 
one  lying  upon  either  side  in  the  closed  space  and  run- 
ning parallel  with  the  phalanx  (Figs,  i  and  2).  Should 
pus  or  edema,  the  result  of  infection,  develop  to  an 
undue  degree  in  this  closed  space,  it  would  have  no 
means  of  free  egress  as  in  the  other  connective-tissue 
space.  Hence  it  would  have  a  tendency  to  shut  off 
the  blood  supply  and  cause  necrosis  of  the  bone.  It 
will  be  seen  by  examining  the  longitudinal  section  that 
the  portion  of  the  bone  involved  is  the  diaphysis, 
since  the  epiphysis  receives  its  blood  supply  before  the 
vessel  enters  the  closed  space.     Anatomically,   then, 


FELONS 


\Li 


V\c..  1 


Transverse  section  of  distal  phalanx,  showing  the  closed  pocket  with  columns 
of  fat  radiating  from  the  bone.  The  glands  are  well  shown  and  demonstrate 
how  easy  it  would  be  for  pathogenic  organisms  to  invade  this  space  through 
these  glands. 


28 


INFECTIONS  OF  THE  DISTAL  PHALANGES 


we  expect  the  epiphysis  to  escape  necrosis  in  these 
cases,  and  cHnical  observation  corroborates  this  view, 
since  the  diaphysis  is  the  part  of  the  bone  which  is  lost. 
This  finds  its  most  perfect  example  in  children  and 
those  whose  epiphyses  and  diaphyses  have  not  pro- 
gressed to  perfect  bony  union.  It  has  been  my  ex- 
perience frequently  to  open  these  old  felons  in  chil- 
dren and  have  the  diaphysis  fall  out  of  the  sac,  where 

Fig.  2 


Longitudinal  section  of  the  distal  phalanx  and  articulation.  Note  the 
closed  pocket  of  the  pulp  of  the  finger  and  the  columns  of  fat,  with  glands 
shown  as  dark  dots  spread  throughout.  Note  that  the  epiphysis  is  well 
separated  from  this  pocket. 

it  has  been  floating,  a  free  body,  in  a  sea  of  pus.  In 
adults,  where  osseous  union  has  taken  place,  an  ex- 
amination will  show  the  necrotic  diaphysis  standing 
out  free  from  the  surrounding  tissue,  with  the  epiphysis 
and  joint,  in  the  early  stages  at  least,  practically 
untouched  by  the  destructive  process. 

This  explanation  of  the  pathological  sequence  would 
seem  to  be  more  reasonable  than  that  of  Roux,  and 
also  explains  the  rapid  recession  of  the  process  after 


FELONS  29 

an  early  opcninp:,  and  the  slow  recovery  when  delay 
has  permitted  the  disease  to  destroy  the  connective 
tissue  which  must  ultimately  be  expelled  as  a  slough. 

When  the  incision  has  been  delayed  or  the  process 
permitted  to  go  on  to  spontaneous  expulsion  of  the 
necrotic  matter,  we  find  a  bluish,  insensitive  pus  bag 
with  a  sinus  opening  which  frequently  appears  at  one 
side  near  the  nail.  As  a  rule,  the  granulation  tissue 
is  not  excessive,  the  sinus  appearing  more  as  a  simple 
canal  uniting  the  pus  pocket  with  the  exterior.  Frag- 
ments of  seminecrotic  connective  tissue  often  appear 
partially  plugging  the  opening. 

Treatment. — The  treatment  of  felons  consists  in 
immediate  incision  into  the  infected  area. 

Certain  errors  are  seen  at  times.  The  first  is  an 
incision  made  into  a  phalanx  in  which  there  is  a  begin- 
ning lymphangitis  and  not  a  localization  in  the  distal 
phalanx.  Such  infections  cause  pain  and  tenderness 
throughout  the  whole  finger,  although  most  marked 
in  the  distal  phalanx.  Again,  the  edema  is  more 
general,  not  having  the  excessive  tenseness  in  the  pulp 
of  the  finger  characteristic  of  a  beginning  felon.  In- 
cision here  is  not  only  unnecessary,  but  positively 
harmful,  as  will  be  brought  out  in  discussing  the  sub- 
ject of  lymphangitis  as  a  whole. 

The  second  error  consists  in  waiting  until  fluctuation 
has  begun.  If  this  is  done,  unnecessary  pain  is  endured 
by  the  patient.  Moreover,  such  destruction  of  the 
connective  tissue,  and  even  of  the  bone,  has  occurred 
as  to  cause  not  alone  prolonged  convalescence,  but 
even  permanent  deformity.  The  incision  should  be 
made  as  soon  as  the  edema  restricted  to  the  distal 
phalanx  has  proceeded  to  a  degree  causing  a  hardness, 
but  not  necessarily  the  board-like  feeling  characteristic 
of  pus  in  other  subcutaneous  areas.  In  general,  one 
may  say  that  when  there  is  present  a  painful,  tender 


30  INFECTIONS  OF  THE  DISTAL  PHALANGES 

distal  phalanx,  with  excessive  edema  limited  to  the 
phalanx,  incision  should  be  made. 

Generally,  the  patient  comes  for  treatment  after  the 
whole  area  is  involved,  but  at  times  the  finger  will  be 
seen  early  enough  to  decide,  because  of  the  localized 
tenderness,  that  the  pus  has  not  extended  throughout 
the  whole  of  the  closed  space,  in  which  case  the  inci- 
sion should  be  made  over  the  localized  tender  area. 
In  those  cases  in  which  there  is  no  localization,  but 
the  whole  phalanx  seems  involved,  the  incision  should 
be  made  somewhat  to  the  side,  and  not  in  the  median 
line,  as  is  unfortunately  frequently  done.  The  median 
incision  leaves  a  scar  over  the  site  of  the  tactile  por- 
tion of  the  finger,  so  that  the  more  delicate  functions 
of  that  part  may  be  impaired.  By  examining  the  cross- 
sections  here  shown  it  will  be  seen  that  this  pocket  can 
be  opened  by  a  lateral  incision  just  as  satisfactorily 
as  by  a  median  one,  and,  in  fact,  somewhat  better, 
since  the  radiating  columns  of  fat  and  connective 
tissue  will  be  cut  transversely,  thus  leading  to  more 
satisfactory  drainage.  If  the  incision  is  made  early, 
one  is  often  surprised  at  the  rapidity  of  the  recovery. 

In  those  cases  in  which  incision  has  been  delayed 
until  necrosis  has  ensued,  certain  phenomena  may  be 
observed.  The  connective  tissue  of  the  pulp  may  be 
so  destroyed  that  pus  will  continue  to  discharge  until 
the  slough  of  seminecrotic  tissue  is  expelled.  If  the 
opening  is  small,  recovery  may  be  hastened  by  remov- 
ing the  detritus  with  tissue  forceps.  Its  removal, 
however,  must  await  the  natural  pathological  processes 
incident  to  all  separation  of  necrotic  from  living  tissue. 

Again,  when  the  bone  is  involved  the  question  often 
arises  as  to  what  disposition  to  make  of  it.  This  will 
vary  with  the  amount  of  involvement.  If  there  is 
complete  separation  of  the  tissues  from  the  diaphysis, 
so  that  it  stands  out  like  a  telegraph  pole  in  a  sea  of 


P.IRONICIII  I  31 

pus,  il  should  be  removed  al  oncv  by  the  Ujiie-euLLing 
forceps,  remembering  that  the  epiphysis  is  not  in- 
volved. In  the  case  of  a  child  the  diaphysis  is  often 
separated  at  the  time  of  incision  or  can  be  easily  cut 
off  with  the  scissors  because  of  the  lack  of  bony  union 
between  the  epiphysis  and  diajihysis.  If  the  bone  is 
exposed  upon  only  i)arl  of  its  circumference  it  will 
frequently  heal  without  further  trouble  and  should 
be  treated  conservatively.  In  those  cases  in  which 
the  diaphysis  is  removed  no  disability  of  the  joint 
need  be  feared  unless  it  has  become  involved,  a  com- 
plication occurring  only  in  a  few  instances.  The  pha- 
lanx will  be  somewhat  short  and  the  finger  nail  may 
be  deformed,  but  movement  will  not  be  seriously 
impaired. 

The  after-treatment  is  the  same  as  that  used  after 
any  incision  in  acutely  infected  areas,  consisting 
essentially  in  procedures  designed  to  relieve  pain  and 
favor  walling-off  of  the  process  by  round-celled  infil- 
tration. Locally  nothing  is  superior  to  the  ordinary 
dressing  saturated  with  hot  boric  acid  solution  until 
the  acuteness  of  the  inflammation  subsides.  The  hand 
is  elevated  to  lessen  the  throbbing  pain.  These  meas- 
ures are  supplemented  by  opiates  if  necessary.  After 
the  acute  inflammation  subsides  the  finger  is  dressed 
by  gauze  thoroughly  saturated  with  vaseline,  which 
permits  the  free  escape  of  pus  and  allows  the  removal 
of  the  dressings  without  pain  to  the  patient. 

PARONYCHIA 

Among  the  infections  of  the  distal  phalanx  is  none 
apparently  so  simple  as  the  paronychia,  or  ''run- 
arounds,"  and  yet  they  frequently  baffle  treatment 
for  some  weeks,  since  the  pathology  may  not  be  under- 
stood. They  begin  ordinarily  at  one  side  of  the  nail 
as  a  simple  infection,  frequently-  from  a  "hangnail." 


32  INFECTIONS  OF  THE  DISTAL  PHALANGES 

This  infection  may  be  of  two  types:  first,  an  acute 
infection,  giving  rise  to  a  small  wheat-grain-sized 
abscess  in  the  subepithelial  tissue  at  the  side  of  "the 
nail,  which,  if  opened,  makes  an  immediate  recovery; 
if  neglected,  it  spreads  along  the  side  of  the  nail  and 
back  to  the  base,  becoming  secondarily  a  typical 
''run-around."  More  often,  however,  this  chronic  type 
develops  from  a  chronic  infection  along  the  edge  of 
a  "hangnail."  For  a  number  of  days  a  drop  of  pus 
or  more  will  exude  from  the  inflamed  area  about  the 
nail  edge.  It  will  then  be  noticed  that  on  the  same  side 
at  the  base  there  is  a  certain  amount  of  swelling  and 
redness,  with  little  or  no  pain.  As  the  days  pass  the 
swelling  and  redness  gradually  extend  about  the  base 
of  the  nail  until  the  opposite  side  is  reached.  At  the 
end  of  two  or  three  weeks  drops  of  pus  will  be  expressed 
from  under  various  parts  of  the  overlying  epithelium 
(eponychium).  A  week  or  two  later  the  entire  nail 
may  be  lifted  off  the  matrix  and  cast  off,  or  at  least 
detached  along  its  entire  base.  Meanwhile,  a  chronic 
discharge  of  pus  continues  from  the  original  nail 
sulcus  from  under  the  eponychium,  since  the  swelling 
and  edema  do  not  favor  satisfactory  drainage.  This 
continues  for  some  time,  during  which  the  matrix 
begins  to  proliferate  freely  and  an  almost  fungus-like 
elevation  of  granulation  tissue  appears  growing  from 
underneath  the  overhanging  cuticle.  This  picture  of 
the  neglected  case  is  not  at  all  uncommon,  owing  to- 
the  habit  of  the  patients  to  consider  this  infection  as 
unimportant  and  consequently  to  treat  it  by  poultices 
and  salves.  In  this  they  are  often  abetted  by  the  ill- 
informed  physician.  At  times,  it  is  true,  spontaneous 
recovery  may  take  place,  but  most  often  the  nail  is 
lost  after  a  more  or  less  prolonged  course. 

Let  us  consider  the  pathology  of  these  chronic 
inflammations  when  they  spread  to  the  base  of  the 


I'.lROXnCIII  I  33 

nail,  it  will  be  found  almost  always  that  llu-  jjiis  is 
under  the  overhanging  edge  of  the  nail.  Ui)on  exten- 
sion the  pus  follows  around  the  nail  sulcus,  still  under 
the  nail.  The  soft  and  delicate  nail  root,  under  the 
eponychium,  is  raised  entirely  off  of  the  nail  bed, 
although  the  distal  exposed  portion  of  the  nail  is  still 
firmly  attached  to  the  matrix. 

Treatment. — With  a  clear  understanding  of  the 
above  pathology,  it  is  manifest  that  the  only  proper 
procedure  is  to  allow  escape  of  this  imprisoned  pus. 
This  is  done  by  making  a  longitudinal  incision  along 
the  outer  edge  of  the  nail,  going  back  to  the  base  as  far 
as  the  sulcus,  wath  special  care,  let  me  repeat,  to  cut  to 
the  outer  side  of  the  nail  so  as  not  to  cut  the  nail  bed 
or  the  overhanging  cuticle,  since  if  this  is  done  it  may 
result  in  a  permanently  split  nail  w^hcn  it  grows  out 
anew.  The  eponychium  is  now  pushed  back  with  a 
sponge  and  the  point  of  a  sharp  scissors  inserted  under 
the  detached  edge  of  the  nail  and  this  is  cut  off,  together 
with  as  much  of  the  root  of  the  nail  as  has  become 
separated  from  the  matrix  by  the  pus.  It  is  W'ise, 
generally,  to  be  on  the  side  of  radicalism,  since  otherwise 
secondary  operations  may  become  necessary.  After 
removing  this  portion  of  the  nail  the  elevated  flap 
of  overhanging  cuticle  is  packed  up  and  out  of  the 
field  by  a  small  strip  of  gauze  saturated  with  vaseline 
to  favor  drainage  for  a  few  days.  A  hot,  moist  dressing 
is  applied  to  the  entire  finger  for  a  couple  of  days,  after 
which  time  a  vaseline  gauze  dressing  or  dry  dressing 
is  applied  as  the  case  may  demand. 

Concerning  those  cases  in  which  more  than  half 
of  the  base  has  become  involved  in  the  swelling  and 
redness,  a  word  further  is  required.  Here  a  second 
incision  should  be  made  upon  the  other  side  of  the 
nail,  using  the  same  precaution  as  in  the  first  incision, 
not  to  cut  the  nail  bed  or  the  overhanging  cuticle 
3  # 


34 


INFECTIONS  OF  THE  DISTAL  PHALANGES 


(Fig.    3).      The    eponychium    which    is    now    entirely 
separated  from  the  epitheHum  on  its  two  sides  is  pressed 

Fig.  3 


Lines  of  incision  used  in  paronychia. 
Fig.  4 


Photograph  of  steps  of  operation  in  paronychia.     Flap  has  been  raised  and 
the  point  of  the  scissors  inserted  under  the  base  of  the  nail. 

back  and  elevated  as  before,  exposing  the  entire  sulcus. 
The  loosened  portion  of  the  nail  in  these  cases  will 


/'.I  RON )'(:///. I 


:]5 


often  comprise  the  entire  nail  root.  This  is  completely 
removed,  leeiving  the  distal  portion  (^f  the  nail  still 
attached  to  the  matrix.  Gauze  is  packed  in  as  before 
to  raise  the  (\ap  and  secure  drainage  (Fig.  4). 

It  is  not  necessary  to  remove  the  distal  portion  if 
it  is  not  already  detached.  It  does  not  interfere  at  all 
with  recovery,  and   is  still  of  some  service  after  the 

Fig.  -5 


Untreated  felon. 


acute  inflammation  at  the  base  subsides.  The  new 
nail  rapidly-  forms,  and  in  growing  out  pushes  the  old 
nail  in  front  of  it  (Figs.  5,  6,  and  7). 

In  those  cases  in  which  the  condition  has  been 
neglected  or  in  which  the  liberating  incisions  have  not 
been  made  at  the  sides,  a  considerable  cauliflower-like 
growth  of  granulations  may  appear,  as  has  already  been 
mentioned.     This  is,   of  course,   due  to   the  irritation 


Fig.  6 


All  inflammation  has  subsided  and  new  nail  is  growing  out,  forcing  the 
old  remnant  ofif. 


Fig.  7 


Complete  recovery  at  the  end  of  seven  weeks. 


SUBEPITHELIAL  ABSCESSES  37 

incident  to  inadequate  drainage.  Hence  we  should  see 
that  the  drainage  is  free.  This  will  be  followed  by  the 
formation  of  nail  and  the  rapid  disappearance  of  the 
granulations.  I  have  never  yet  cauterized  these.  In 
one  intractable  case  rapid  relief  was  secured  by  placing 
a  rubber  band  about  the  base  of  the  finger,  producing  a 
Bier's  hyperemia  for  some  days. 

SUBEPITHELIAL  ABSCESSES 

It  is  not  at  all  uncommon  for  subepithelial  infections 
to  take  place  either  as  local  processes  or  associated 
with  more  extensive  infections.  The  epithelium  may 
be  raised  over  a  considerable  area,  both  upon  the  flexor 
and  the  extensor  surfaces.  As  a  local  process  this  kind 
of  infection  is  frequently  seen  about  the  distal  phalanx, 
the  contents  being  generally  a  seropurulent  fluid  of 
low  grade  of  virulency. 

The  treatment  consists  in  removing  the  elevated 
epithelial  covering  and  applying  some  dry  dressing  or 
hot  boric  dressing  as  the  virulency  of  the  case  demands. 
It  is  essential  that  every  part  of  the  detached  epithe- 
lium be  removed;  otherwise,  the  moist,  warm  pocket 
will  favor  the  further  development  of  the  infection. 


CHAPTER    III 
CARBUNCULAR  INFECTIONS 

The  carbuncles  which  develop  on  the  hand  are 
typical  of  that  condition  elsewhere.  Carbuncles,  al- 
though seen  frequently,  are  often  not  understood  by 
the  practitioner,  who  does  not  take  the  proper  steps 
necessary  to  their  immediate  cure. 

They  may  develop  in  any  portion  of  the  dorsum 
containing  hair  follicles,  their  most  common  site,  there- 
fore, being  the  dorsum  of  the  proximal  phalanges 
(Figs.  II  and  12)  and  the  back  of  the  hand  upon  the 
ulnar  side.  The  various  types  of  staphylococci  are 
most  often  the  exciting  organisms.  The  peculiar 
pathology  characteristic  of  this  condition  is  due  to 
the  nature  of  the  skin  and  subcutaneous  tissue  with 
its  sweat  glands,  hair  follicles,  and  columns  of  fat 
extending  up  into  the  derma. 

Anatomical  Considerations  and  Pathogenesis. 
— In  an  attempt  to  determine  the  source  of  these 
infections  and  the  cause  of  their  persistence,  I  made 
serial  sections  of  a  portion  of  the  skin  and  identified 
the  various  structures  in  the  succeeding  sections,  with- 
out, however,  being  able  to  say  definitely  that  the 
source  could  be  attributed  to  either  the  sweat  glands 
or  hair  follicles  alone.  Repeatedly  on  examination  a 
hair  follicle  with  its  sebaceous  gland  could  be  found  in 
the  subjacent  columnse  adiposse;  on  the  other  hand, 
it  almost  as  frequently  occurred  that  the  convoluted 
sweat  gland  would  also  be  found  (Figs.  8  and  9).  One 
could  only  conclude,  therefore,  that  it  was  possible 
for  the  carbuncle  to  begin   from  either,   although  it 


A  N  ATOM  I  C.I  L  CONSIDERATIONS  AND  PAIIIOGENESIS    ;',9 

seemed  more  reasonable  Lo  aUribuLe  ils  scnirce  lo  ihe 
hair  and  its  sebaceous  gland.  Garre,  Budinger,  and 
others  have  demonstrated  upon  themselves  that  it  is 
very  easy  to  produce  such  infections  by  rubbing  into 
the  skin  virulent  streptococcus  cultures. 

Fig.  8 


Sagittal  section  of  the  skin  showing  columna  adiposa.  At  the  upper  part 
note  the  hair  folHcle  with  its  sebaceous  glands  connecting  this  column  of 
fat  with  the  skin.     In  the  lower  portion  of  the  column  of  fat  a  sweat  gland 


In  the  accompanying  rnicroscopic  illustration  of  a 
cross-section  of  the  skin,  the  various  columucie  adiposa? 
may  be  seen  with  the  hair  follicles,  sebaceous  glands, 
and  sweat  glands  in  various  locations  (Fig.  lo).  From 
a  study  of  this,  the  course  an  infection  will  pursue  can 
be  seen  readily.      Beginning  in   one  of  the  colunuune, 


40 


CARBUNCULAR  INFECTIONS 


the  accumulation  finds  readier  escape  downward  into 
the  subjacent  fat.  From  there  it  spreads  laterally  and 
gradually  fills  the  loose  mesh  under  the  skin  and  ascends 
into  the  various  columnse,  from  whence  the  infection 
extends  to  the  surface  from  these  many  sources,  strain- 
ing through  a  sieve,  as  it  were.  As  the  process  persists 
the  central  part  of  the  surface  becomes  necrotic,  and 


Fig.  c 

) 

ilL 

?ap 

:*-#— 

ISIHifll^tfdS^^BI 

^ 

f 

gtt 

^^-'li:*;W*'-v  '■ 

1^ 

'  \ 

^.   '^ 

-J 

•mm 

Hp 

^^^' 

r  ^^^wB^P  " 

' 

3Bi.i!ti  -i 

.  "^i^fcViiw  ^■_^-s:!'' 

.n  «ei?i.-~si5&u«j]»«a)ft!es-v  t»'-^ "  - 

Section  parallel  to  the  skin.  Note  that  here  we  have  two  columns  adi- 
posse  cut  transversely.  In  one  a  hair  is  seen  and  in  the  other  a  hair  and  a 
sweat  gland.  It  is  readily  seen  how  pus  would  follow  along  these  to  the 
surface. 


through  this  is  extruded  pus  and  seminecrotic  con- 
nective tissue.  Even  this  does  not  give  free  drainage, 
and  the  process  still  tends  to  extend  around  the  periph- 
ery. Meanwhile,  more  and  more  of  the  overhanging 
skin  becomes  destroyed,  until  such  a  time  as  enough 
surface  is  destroyed  to  give  free  exit  to  the  pus  and 
the  surrounding  inflammatory  infiltration  walls  off  the 
infection,  which  it  does  with  difficulty,  owing  to  the 


TREATMENT 


41 


nuin>    iiiursticcs  in    the   loose   mesh   of  subcutaneous 
tissue  through  which  the  pus  can  exU  lul.     An  exami- 
nation of  a  schematic  cross-section 
of  such  an  inflamed    area  shows  '^^' '° 

these  various  facts.  CHnically 
they  are  observed  on  the  surface 
as  follows:  First,  the  central  ne- 
crotic area:  about  this  the  area 
of  tissue  shows  punctate  pus 
exudations,  and  beyond  this  a 
bluish  circumference  through 
which  the  pus  has  not  penetrated, 
although  it  is  under  the  skin, 
and  finally,  surrounding  it  all,  an 
area  of  induration  denoting  in- 
flammatory reaction. 

Treatment. — These  cases  are 
best  treated  by  a  crucial  incision, 
the  ends  of  which  extend  beyond 
the  edge  of  infiltration,  followed 
by  incisions  under  the  skin,  so 
that  this  may  be  raised  off  of  the 
underlying  tissue  (Figs.  1 1  and 
12).  The  base  of  the  flaps  should 
correspond  with  the  ends  of  the 
crucial  incisions.  Hot,  moist  gauze 
is  now  packed  under  the  flaps  to 
insure  drainage.  The  patients  are 
always  anesthetized,  nitrous  oxide 
being  preferable.  The  reasons 
for  carrying  the  incisions  in  the 
skin  beyond  the  edge  of  inflam- 
matory exudation,  as  indicated 
by  the  induration,  are  difUcult 
to  understand.  The  principle  is 
directly  opposed  to  the  ordinary 


A  section  of  the  skin, 
subcutaneous  tissue,  and 
muscle,  showing  the  area 
in  which  the  pus  of  a  car- 
buncle develops  and  how 
it  spreads  beneath  the  skin 
and  comes  to  the  surface 
through  the  various  dark 
lines  in  the  skin  which 
represent  the  hair  follicles. 
Note  several  dark  dots  in 
the  fat  underneath  the  skin. 
These  are  cross-sections 
of  hairs  which  have  pene- 
trated beneath  the  skin 
and  lie  in  the  fat. 


42 


CARBUNCULAR  INFECTIONS 


conception  of  this  area  as  a  protecting  wall,  which  in 
other  conditions  we  would  use  every  possible  precaution 
to  preserve.  Of  the  advisability  of  the  length,  however, 
I  have  no  doubt,  since  I  have  had  occasion  to  use  this 
method  in  probably  30  cases,  and  whenever  the  tech- 

FlG. II 


Schematic  drawing  showing  the  areas  of  the  carbuncle  with  the  length 
of  incisions  upon  the  skin. 


nique  described  has  been  faithfully  carried  out  the  result 
has  always  been  satisfactory.  If,  however,  through  a 
conservatism  I  fell  short,  the  extension  always  took 
place  along  that  area,  while  the  sides  where  I  had  made 
the  long  incisions  would  go  on  to  satisfactory  recovery. 


TREATMENT 


4:} 


This  same  holds   true  for  carbuncles  of  the  neck  and 

other  areas. 

Fig.  12 


Schematic  drawing  showing  areas  of  infection  in  the  carbuncle  and  the 
method  by  which,  through  a  transverse  incision  parallel  to  the  skin,  the 
flaps  are  raised  up.  Note  that  this  incision  F  goes  to  the  limit  of  the  area 
of  induration  A;  B,  area  of  round-celled  infiltration  and  some  pus;  C,  area 
of  pus,  most  of  the  fat  being  destroyed;    D,  area  of  necrosis. 

The  cuts  parallel  to  the  skin  designed  to  free  the 
skin  from  the  deep  fascia  should  be  made  about  mid- 
way between  these  two  layers  going  back  through  the 
area  of  induration  also  (Fig.  12).     Any  arterial  l)Ieeding 


44  CARBUNCULAR  INFECTIONS 

is  stopped,  but  the  venous  oozing  is  controlled  by  pack- 
ing, and  this  packing  should  be  sufficient  to  raise  the 
flaps  well  up.  The  packing  is  removed  at  the  end  of 
twenty-four  hours,  and  the  flaps  allowed  to  fall  back. 
If  there  is  not  much  venous  oozing,  the  gauze  is  thor- 
oughly saturated  with  vaseline,  which  allows  drainage 
and  permits  removal  without  pain  to  the  patient. 

If  there  is  any  free  slough  it  is  removed  at  the  time 
of  operation.  It  is  not  necessary  to  curette  or  cut 
away  any  tissue  whatever.  The  removal  of  any  of  the 
skin,  no  matter  how  much  damaged  and  fragmentary, 
should  be  condemned,  since  one  is  always  surprised 
at  the  rejuvenation  of  apparently  hopelessly  injured 
skin.  I  have  often  found  the  flaps  to  fall  into  place 
and  leave  a  granulating  area  no  larger  than  a  dime, 
where  it  had  seemed  the  entire  area  must  be  lost.  For 
that  reason  also  one  should  condemn  most  severely 
the  procedure  advocated  by  some  of  excising  the  entire 
area.  On  the  other  hand,  the  crucial  incision  alone, 
without  raising  the  flaps,  is  futile  in  almost  all  cases 
and  certainly  prolongs  convalescence. 

Case  I. — In  this  connection  the  history  of  a  patient 
sent  me  for  treatment  is  interesting.  When  the  patient 
was  first  seen  he  had  been  suffering  for  three  weeks 
with  a  carbuncle  on  the  dorsum  of  the  left  hand.  It 
had  begun  as  a  small  pimple  on  the  ulnar  side,  and 
incisions  had  been  made  on  six  different  occasions  at 
different  points.  The  infection  had  spread  to  involve 
the  entire  dorsum,  and  had  extended  to  the  flexor 
surface  around  the  thumb  and  the  wrist  at  the  ulnar 
side.  The  sloughing  connective  tissue  was  being  ex- 
truded from  the  incisions  and  small  necrotic  ostea 
which  had  appeared  over  its  surface.  In  other  places 
it  had  the  characteristic  appearance  of  a  carbuncle. 

The  patient  was  anesthetized  and  a  crucial  incision 
made,    not,    however,    carrying   the   incision    the   full 


DIFFERENTIAL  D//1CN0SIS  45 

k'np:lh  of  the  infected  area,  for  fear  of  impairing  the 
nutrition  of  the  flaps.  The  entire  area,  however,  was 
undermined  and  gauze  saturated  with  hot  boric  acid 
solution  carried  to  the  edge.  An  immediate  cessation 
of  the  process  took  place  except  at  the  wrist,  where  a 
subsequent  incision  had  to  be  made,  owing  to  the 
inadequacy  of  the  early  incision.  When  the  flaps 
finally  healed,  it  was  found  that  no  grafting  was  neces- 
sar}^  So  much  of  the  skin  had  retained  its  vitality  that 
the  denuded  areas  were  soon  covered  by  epithelium. 

At  times  I  have  been  compelled  to  cover  a  small 
denudation  by  a  Thiersch  graft  from  the  patient's 
body.  This  should  be  done  as  soon  as  a  good  granu- 
lating base  has  been  assured.  This,  in  my  experience, 
is  more  often  necessary  on  the  dorsum  of  the  finger 
than  on  the  back  of  the  hand. 

The  illustrations  show,  in  both  cases,  beginning 
carbuncles  (Figs.  13  and  14).  The  one  on  the  finger 
had  been  treated  a  week  before  it  came  under  my 
observation,  and,  after  incision,  was  dressed  only 
twice  and  was  entirely  well  in  a  week.  The  one  on  the 
dorsum  of  the  hand  had  been  treated  for  six  days 
after  a  simple  incision.  After  opening  it  properly  and 
applying  the  Bier  suction  cup,  which  I  have  used  at 
times  with  success,  entire  healing  followed  in  a  week. 
This  picture  of  an  apparently  simple  case  is  presented, 
since  it  is  in  such  that  the  diagnosis  is  not  made.  They 
are  considered  simple  abscesses.  The  more  severe 
cases  with  the  punctate  areas  of  pus  are  recognized 
by  all  if  they  are  acute. 

Differential  Diagnosis, — Oidiomycosis. — There  is 
a  more  chronic  type  of  infection  of  this  area  which 
may  be  mistaken  for  oidiomycosis  (blastomycosis), 
and,  conversely,  an  oidiomycosis  may  be  construed  to 
be  a  subacute  carbuncle.       The  appearance  of  these 


46 


CARBUNCULAR  INFECTIONS 


oidiomycotic  areas  is  very  characteristic,  presenting  a 
rather  clean  granulating  surface,  while  the  edge  which 

Fig.  13 


Beginning  carbuncle  on  the  ulnar  side  of  the  dorsum  of  the  hand. 

Fig.  14 


Carbuncle  on  the  dorsum  of  the  proximal  phalanx. 

is  undermined  appears  as  if  motheaten,  with  pus  drop- 
lets exuding  through.     In  some  parts  the  process  will 


DIIIERENTI.II.  1)1  l(;\()SIS  47 

apparently  liave  healed  and  be  covered  by  a  ihin, 
shinin.c  sheet  of  epithelium.  Over  the  granulating^  area 
the  skin  is  not  completely  destroyed,  since  areas  of 
epithelium  remain  which  rapidh'  produce  epidermiza- 
tion  when  the  process  is  halted. 

The  diagnosis  can  be  made  readil>-  b>-  securing  pus 
from  the  abscess  and  examining  the  unstained  smear 
diluted  with  4  per  cent.  KOH,  (jr  with  normal  salt 
solution.  This  finding  may  be  corroborated  by  micro- 
scopic examination  of  the  skin  w^hich  will  show  the 
proliferating  rete  with  miliary  abscesses. 


Fig. 

15 

1 

1 

iP^^- 

■L^ 

^ 

1 

■ 

H 

m 

ff^ 

1 

Ik 

^^H 

'- 

I^P 

■4^ 

« 

^ 
^ 

^"^ 

1 

^^ 

^^^^m^ 

Hi 

B2^  ^^^^^BH 

Oidiomycosis.  (Photograph  loaned  by  Dr.  Ormsby.)  Typical  and  prac- 
tically identical  with  that  seen  in  the  case  described  in  the  accompanying 
description. 

One  such  case  came  under  my  care  in  which  the 
condition  had  been  held  to  be  a  chronic  infection  and 
had  been  treated  with  salves  and  applications  until 
the  entire  dorsum  was  covered  by  the  ulcerated  area. 
The  edges  were  curetted  thoroughly-  and  potassium 
iodide  given  in  large  doses  (400  grains  per  day).  The 
lesion  finally  healed  after  some  weeks,  during  which 
it   was    necessary    to    remove    the   extending   edge    in 


48  CARBUNCULAR  INFECTIONS 

various  parts  several  times.  Unfortunately,  I  have 
not  a  photograph  of  the  lesion,  but  it  was  practically 
identical  with  that  shown  by  the  photograph  of  the 
same  condition  in  another  patient  kindly  loaned  me 
by  Dr.  Ormsby  (Fig.  15). 

Case  II. — Mr.  G.  C,  of  Gallion,  Ohio,  was  referred 
to  me  with  the  history  that  seven  months  before  he 
noticed  a  small  pimple  on  the  dorsum  of  the  right  hand. 
The  patient  opened  the  pimple  with  the  scissors,  fol- 
lowing which  the  sore  began  to  spread  by  peripheral 
extension.  A  couple  of  weeks  later  a  similar  lesion 
began  on  the  neck,  as  a  result  of  the  patient  scratch- 
ing a  pimple  there.  These  two  lesions  continued  to 
spread  until  about  three  weeks  before  I  saw  the  patient, 
when  two  small  pustules  appeared  upon  the  right  arm, 
and  since  that  several  small  lesions  had  appeared  on 
the  trunk,  all  possibly  implanted  through  self-con- 
tamination by  scratching.  The  lesion  on  the  hand 
was  of  approximately  the  size  shown  in  the  illustration. 
That  upon  the  neck  was  about  one  and  one-half  inches 
in  diameter.  The  characteristic  appearance  already 
described  was  present.  The  areas  were  excised,  follow- 
ing which  all  the  lesions  disappeared  except  that  upon 
the  hand.  This  also  finally  disappeared  under  curet- 
tage and  large  doses  of  potassium  iodide. 

The  condition  is  essentially  different  from  the  pic- 
ture presented  by  the  foul  sloughing  syphilitic  ulcer 
or  the  blue  undermined  tuberculous  process. 

Chronic  Staphylococcus  Processes. — We  may  have  a 
chronic  staphylococcus  process  upon  the  dorsum,  as 
has  already  been  said,  which  may  be  wrongfully  diag- 
nosticated as  oidiomycosis.  Such  a  case  came  under 
my  observation  with  an  ulceration  upon  the  dorsum 
which  had  involved  during  its  course  a  greater  part 
of   the   area,    some   parts,  however,  showing   pinkish, 


DlllERENTl.lL  DIAGNOSIS 


49 


p^listoiiinp:  now  epidermis,  while  others  showed  active 
process  appearing  as  an  ulcerating  granulating  surface, 
or  rather  as  a  depressed  verrucous  process,  while  the 
edges  of  these  areas  showed  the  advancing  border  of 
infection.  Repeated  examinations,  both  by  culture  and 
microscopic  tissue  study,  demonstrated  a  pure  culture 
of  staphylococcus.  It  is  my  belief  that  the  process 
had  become  chronic  in  its  nature,  owing  to  the  peculiar 

Fig.  i6 


Chronic  staphylococcus  infection  of  the  dorsum  simulating  oidiomycosis. 
(See  case  report,  Pyle.) 


anatomy  I  have  described  as  being  found  here,  coupled 
with  lowered  resistance  to  the  specific  organism  and  the 
irritation  of  the  various  treatments  to  which  it  had 
been  subjected.  It  healed  rapidly  under  bland,  slightly 
antiseptic  applications.  It  is  ni}'  opinion  that  a  passive 
hyperemia  produced  by  local  suction  cups  would  also 
have  hastened  recovery  in  this  case.     An  autogenous 

4 


50  CARBUNCULAR  INFECTIONS 

vaccine  might  also  have  helped.  The  case  history, 
written  by  the  patient,  who  was  a  physician,  is  ap- 
pended. The  photograph  (Fig.  i6)  shows  the  condition 
inadequately. 

Case  III. — Family  history  negative;  aged  forty-four 
years;  good  health.  On  September  12,  1910,  I  noticed 
skin  on  middle  knuckle  of  right  hand  flecked  up  as  if 
by  a  pin.  On  the  morning  of  the  15th  I  noticed  some 
reddening  of  the  knuckle  extending  up  into  the  back 
of  the  hand,  with  a  slight  burning  pain.  On  the  morn- 
ing of  the  1 6th  my  hand  was  badly  swollen.  Pain 
very  severe  when  hand  hung  down,  and  burning  was 
intense. 

I  treated  it  vigorously  with  wet  dressings  of  bichlo- 
ride, carbolic  acid,  and  boracic  acid  alternately.  The 
swelling  subsided  in  a  few  days.  The  pain  was  not  so 
severe,  but  the  burning  sensation  continued.  The 
place  where  the  infection  started  broke  down,  forming 
something  like  a  small  ulcer.  The  infection  then 
seemed  to  extend  up  the  back  of  my  hand.  Every 
hair  follicle  seemed  to  be  a  centre  of  infection,  breaking 
down  and  forming  a  small  opening  from  which  exuded 
pus.  I  treated  it  with  iodine,  carbolic  acid,  ointments 
of  every  description,  dry  and  wet  dressings.  With  all 
the  treatment  the  infection  continued  to  spread  over 
the  back  of  the  hand,  with  more  or  less  pain  all  the 
time,  but  increasing  at  intervals,  the  burning  being 
almost  continuous. 

On  December  25,  19 10,  becoming  disgusted  with  my 
own  treatment,  and  upon  advice  of  my  neighboring 
doctors,  I  left  for  Chicago.  There  my  hand  was  ex- 
amined by  a  number  of  prominent  physicians.  Each 
man  had  a  diagnosis  of  his  own.  Dr.  W.  L.  Baum's 
diagnosis  was  staphylococcus  infection.  His  diagnosis 
was  proved  by  both  culture  and  the  microscope.  This 
was  corroborated  by  Dr.   Kanavel. 


DIFFERENTIAL  DIAGNOSIS  51 

Was  under  treatment  of  these  physicians,  which 
consisted  of  a  bland,  shghtly  antiseptic  ointment, 
two  weeks  before  I  noticed  much  change;  but  within 
three  weeks  from  the  time  they  started  treatment  my 
hand  was  thoroughly  healed,  leaving  a  red  scar,  which 
yet  remains.  The  scar  resembles  that  of  a  severe  burn 
extending  over  the  entire  back  of  the  hand. 


CHAPTER  IV 
MISCELLANEOUS  ABSCESSES 

COLLAR-BUTTON    ABSCESS    (SHIRT-STUD    ABSCESS) 
(FROG  FELON) 

Among  the  local  infections  of  the  hand  none  is  more 
typical  than  the  collar-button  abscess,  or,  as  the  French 
describe  it,  en  houton  de  chemise.  This  is  an  abscess 
located  at  the  distal  edge  of  the  palm  under  the  dermal 
and  epidermal  tissues.  Its  peculiar  character  is  due 
to  the  fact  that  at  this  site,  in  workingmen,  the  epithe- 
lium becomes  markedly  hypertrophied,  making  a  dense 
sheet  under  which  the  pus  spreads.  An  infection 
present  under  the  derma  passes  through  this  to  the 
epiderma^l  tissue,  where  a  second  abscess  forms,  thus 
producing  a  dumb-bell-shaped  accumulation  of  pus.  The 
pus  may  locate  primarily  in  the  epidermic  space  and 
erode  through  the  dermal  tissue  rather  than  through 
the  dense  epidermis  to  the  surface,  producing  the 
same  condition.  It  is  possible  that  this  latter  course 
is  more  common  than  the  former. 

These  abscesses  doubtless  owe  their  origin  to  the 
lessened  resistance  due  to  trauma  more  than  those 
developing  elsewhere;  for  here  the  thickened  area  of 
superficial  cornified  epithelium  is  frequently  opened  by 
cracking,  infection  ensues  in  the  deeper  area  by  lym- 
phatic extension,  or,  if  the  cracks  are  deep,  by  direct 
inoculation.  Here  it  finds  excellent  food  for  devel- 
opment, since  the  repeated  trauma  has  lowered  the 
normal  resistance  found  in  healthy  tissue. 

In  this  connection  attention  should  be  drawn  to  the 
fact  that  at  the  lower  or  distal  end  of  the  palmar 


COLLAR-BU TTON  JBSCESS 


53 


aponeurosis  the  sheet  may  become  very  thin  in  spots, 
particularly  between  the  processes  which  blend  with 
the  tendon  sheaths  and  the  superficial  transverse  liga- 
ment, and  hence  above  the  canal  for  the  lumbrical  mus- 
cles. Here,  by  noting  one's  hand,  slight  elevations  of 
tissue  may  be  seen,  cushions  of  fatty  tissue.  When  pus 
accumulates  at  this  point  it  spreads  very  easily  into 
the  web  of  the  finger,  and  in  those  anomalous  cases 
where  the  fascia  is  lacking  to  any  extent  these  shirt- 


FiG.  17 


Schematic  drawing,  showing  distal  paknar  abscess  and  its  extension  into 
the  dorsal  tissue  between  the  fingers. 

button  abscesses  would  enter  the  fat  space  and  spread 
down  into  the  cellular  tissue  of  the  web  pointing  on 
the  dorsum  between  the  bases  of  the  fingers.  Then  the 
dumb-bell  abscess  would  have  from  its  second  chamber 
a  connection  with  a  still  larger  one  on  the  dorsum,  a 
sort  of  chain  of  lakes  of  pus  (Fig  17). 

In  relation  to  this,  two  very  interesting  cases  can 
be  cited,  showing  how  infection  apparently  in  nearly 
the  same  site  may  occupy  different  spaces. 


54  MISCELLANEOUS  ABSCESSES 

Case  IV. — From  Northwestern  University  Medical 
School  Dispensary.  History:  C.  B.,  carpenter  by  trade, 
has  been  using  a  chisel  several  days  in  succession 
almost  constantly.  He  hits  the  handle  of  the  chisel 
with  the  palm  of  the  hand  to  force  it  along.  Two  days 
ago  the  patient  began  to  note  tenderness  at  the  distal 
portion  of  the  palm  between  the  base  of  index  and 
middle  fingers,  about  2  cm.  from  web.  Upon  examina- 
tion this  was  found  to  be  tender  to  pressure,  and  had 
considerable  local  hardness.  Slight  edema  of  dorsum. 
Temperature,  99°;  pulse,  85. 

Treatment. — -Incision  was  made  over  the  area  and  a 
small  amount  of  pus  evacuated.  This  was  under  the 
deeper  layers  of  skin  lying  upon  the  transverse  fascia 
in  the  pad  of  fat  found  in  this  region. 

Case  V. — E.  A.  Applied  to  dispensary  of  North- 
western University  Medical  School  November  5,  1904. 
The  patient  noticed  pain  and  tenderness  at  base  of 
ring  and  middle  fingers,  about  1.5  cm.  from  web. 
Swelling  and  redness  had  been  increasing  for  four  days. 
Temperature,  99°;  pulse,  86.  Local  swelling  and  red- 
ness at  site  noted,  involving  web  also,  but  most  marked 
above.     Tenderness  noted  as  severe. 

Diagnosis. — Abscess,  subdermal,  above  aponeurosis. 
Operation:  ethyl  chloride  spray,  and  incision  made 
over  site  of  greatest  tenderness,  down  through  deep 
layers  of  palmar  skin.  Moderate  amount  of  pus 
escaped,  and  upon  inserting  probe  the  larger  part  of 
the  pus  was  found  to  be  in  the  cellular  tissues  of  the 
dorsal  web  area,  |  inch  back  from  web.  Through-and- 
through  drainage  inserted. 

November  9,  nearly  well.     Patient  did  not  return. 

Here  we  see  two  abscesses,  to  all  appearances  in  the 
same  place,  yet  in  reality  very  different,  being  so  near 
the  distal  edge  of  the  transverse  ligament  that  while 


ABSCESSES  /.V   TIIES.IR  .IM)  IIY ro'lll EX .1 1<  S/'.ICES     55 

one  was  conliiRd  U)  ihc  sLilxJcniial  tissue,  the  second 
had  invaded  the  adjacent  cellular  tissue  of  tiie  web  and 
spread,  by  conlinuity  of  spaces,  into  the  loose  tissui' 
of  the  dorsum  where  most  of  the  pus  was  localized. 

Treatment. — -The  treatment,  therefore,  consists  in 
being  certain  that  the  second  pocket  is  opened  if  it 
be  present,  and  not  being  content  when  after  incising 
free  discharge  of  pus  is  noted.  Always  examine  care- 
fully by  inspection  or  a  probe  for  the  second  pocket. 
If  the  pus  has  extended  to  the  space  in  the  web,  it 
may  be  drained  by  a  through-and-through  incision 
from  the  palmar  to  the  dorsal  surface  through  the  web. 
I  have  at  times  cut  the  web  completely  without  noting 
any  subsequent  impairment  of  function. 


LOCALIZED   ABSCESSES   IN   THE   THENAR  AND   HYPOTHENAR 

SPACES 

In  the  thenar  region  several  minor  and  indefinite 
spaces  lie  beneath  not  only  the  skin,  but  also  the  fascia 
which  covers  the  muscles.  The  areas  are  small,  how- 
ever, and  are  generally  opened  through  the  adjacent 
skin  before  any  serious  damage  occurs.  It  is  in  these 
areas  more  often  than  the  thenar  space  proper  that 
direct  infection  from  puncture  takes  place,  since  the 
latter  lies  rather  deeply,  and  to  invade  it  the  puncture 
should  enter  betw-een  the  muscular  body  and  the  ad- 
duction crease,  rather  than  upon  the  prominent  part  of 
the  thenar  eminence.  It  is  w^ell  to  bear  this  in  mind 
in  making  a  diagnosis  as  to  whether  the  thenar  space 
is  involved  or  not,  since  a  minor  infection  in  the  super- 
ficial tissues  of  the  thenar  area  either  upon  the  palmar 
or  dorsal  surface  may  be  associated  with  great  edema 
upon  the  dorsum,  and  thus  confuse  the  surgeon  and 
lead  to  a  diagnosis  of  pus  in  the  thenar  space  w^hen  it 
is  uninvolvcd.    This  error  occurred  in  one  of  mv  cases, 


56  MISCELLANEOUS  ABSCESSES 

and  is  of  particular  interest,  since  it  demonstrates  that 
treatment  based  upon  this  improper  diagnosis  may 
not  produce  serious  results,  for  here  it  will  be  noted 
that  no  disastrous  sequelae  followed  the  opening  of 
the  uninfected  space  in  conjunction  with  an  abscess 
of  the  subcutaneous  tissue. 

Case  VI. — E.  K.  Injured  December  12,  1904,  at 
stockyards,  by  running  foreign  body  into  thenar 
eminence  at  about  middle  of  palmar  surface.  All  signs 
of  localized  infection  followed,  and  on  December  16 
patient  applied  to  dispensary  for  treatment.  Diag- 
nosis of  infection  of  the  thenar  space  made  and 
through-and-through  drainage  of  thenar  area  insti- 
tuted, under  gas  anesthesia.  It  was  seen  that  the 
dorsal  subcutaneous  tissue  only  contained  pus;  tube 
was  withdrawn  and  dorsal  opening  enlarged.  Patient 
made  rapid  recovery,  and  was  discharged  in  ten  days, 
apparently  fully  recovered. 

The  hypothenar  area  is  a  closed  space,  as  will  be 
shown  later,  infection  practically  always  arising  from 
direct  implantation  and  localizing  at  that  site.  It 
does  not  spread  out  of  the  space.  Therefore,  there  is 
nothing  peculiar  in  its  pathology  and  the  treatment  of 
its  abscesses  consists  in  simple  incision. 


PART    II 

GRAVE  INFECTIONS:    TENOSYNOVITIS, 
FASCIAL    SPACE    ABSCESSES,    LYM- 
PHANGITIS,   AND    ALLIED 
CONDITIONS 


CHAPTER    V 

DIAGNOSIS  IN  GENERAL 

It  is  the  purpose  of  this  chapter  to  give  in  general 
the  diagnostic  factors  of  the  three  severe  types  of 
infection,  viz.,  lymphangitis,  tenosynovitis,  and  fascial 
space  infection.  It  is  not  intended  in  any  sense  as  a 
complete  discussion  of  any,  but  is  introduced  with  the 
idea  that  by  reading  this  the  beginner  may  be  able 
in  an}^  given  case  to  make  his  diagnosis  in  general, 
and  thus  be  directed  to  the  more  extensive  subsequent 
discussions  for  corroboration.  Therefore,  in  various 
parts  indication  is  made  where  these  can  be  found.  It 
is  desirable  to  emphasize  this,  since  the  greatest  diffi- 
culty to  be  met  in  these  cases  is  the  diagnosis.  Unfor- 
tunately, a  snap  diagnosis  is  too  often  made  and 
incisions  hastily  carried  out  which  jeopardize  the  life 
of  the  patient  and  the  use  of  a  hand,  when  a  little  more 
care  in  the  diagnosis  would  have  led  to  an  immediate 
cure.  It  should  be  emphasized,  further,  that  if  careful 
study  is  made  it  is  possible  in  nearly  every  case  to 
diagnosticate  not  alone  the  nature  of  the  infection,  but 
also  the  location  of  the  pus  if  it  be  present. 


58  DIAGNOSIS  IN  GENERAL 

There  are  certain  facts  which  should  be  remembered : 

1.  The  location  of  the  greatest  swelling  does  not 
indicate  the  position  of  the  pus.  The  excessive  swelling 
comes  in  those  areas  where  there  is  the  largest  amount 
of  loose  cellular  tissue,  i.  e.,  upon  the  dorsum,  while 
in  nine  cases  out  of  ten  the  pus  is  on  the  flexor  surface. 

2.  The  site  of  the  greatest  tenderness  is  of  marked 
importance  in  the  location  of  the  pus. 

3.  The  three  types  of  infection,  viz.,  lymphangitis, 
tenosynovitis,  and  fascial  space  infection,  in  the  majority 
of  cases  are  distinct  processes,  one  type  alone  being 
present  in  a  given  case.  At  times  the  types  may  be 
combined. 

4.  The  treatment  of  the  three  types  is  essentially 
different,  and  the  gravest  of  errors  will  be  made  if 
they  are  not  differentiated,  since  their  treatment  is 
diametrically  opposed  (see  pp.  251  and  351). 

Let  us  now  take  up  these  three  types  in  order. 

LYMPHANGITIS 

Lymphangitis  may  be  either  superficial  or  deep. 
Deep  lymphangitis  may  end  in  tenosynovitis  or  ab- 
scess formation  in  the  deep  tissues.  Most  often,  how- 
ever, this  does  not  take  place.  There  is  rapid  increase 
of  swelling  of  the  whole  hand  and  forearm,  with  the 
greatest  redness,  swelling,  and  tenderness  upon  the 
dorsum.  Some  red  lines  of  lymphatic  infection  may 
be  seen  running  up  the  arm,  to  the  axilla  or  elbow. 
There  is  an  absence  of  pain  on  extension  of  the  fingers 
and  thumb.  The  fingers  can  be  moved  voluntarily 
without  pain,  and  there  is  an  absence  of  tenderness 
over  the  tendon  sheaths  and  the  middle  palmar  and 
thenar  spaces.  There  is  the  absence  of  bulging  of  the 
palm,  although  the  concavity  may  be  lost.  The  patient 
often  presents  great  prostration  (see  pp.  328  and  333). 

The  superficial  type  lacks  the  great  swelling  of  the 


TENDS  YNOVI TIS  59 

entire  hand  and  forearm.  We  receive  a  history  of  a 
sHght  abrasion  or  injury  on  the  hand;  within  a  short 
time  the  patient  complains  of  all  the  symptoms  of 
systemic  absorption — headache,  thirst,  sleeplessness, 
restlessness,  and  fever.  On  examination  we  see 
locally  an  area  of  suffused  redness,  with  a  swelling  of 
the  fmger  which  is  involved.  The  color  seldom  becomes 
of  that  violaceous  tint  seen  in  abscess  formation  or  the 
pallor  which  succeeds  it.  In  the  most  acute  types  there 
may  be  little  or  no  edema,  but  most  often  one  finds  a 
considerable  edema  most  marked  upon  the  back  of  the 
hand.  The  swelling  varies  with  the  site  of  the  invasion. 
A  general  rule  may  be  enunciated.  The  lymphatics 
pursue  the  shortest  course  to  the  back  of  the  hand.  In 
other  words,  if  the  infection  enters  at  the  distal  part 
of  the  palm  the  course  will  lie  between  the  bases  of 
the  fingers.  The  lymphatics  upon  the  dorsum  will 
show  up  as  bright  red  streaks  running  up  the  arm. 
Ordinarily  one  or  two  only  will  be  seen  upon  the  back 
of  the  forearm,  although  there  are  fifteen  to  twenty 
here.  The  lymphatics  from  the  little  finger  and  ring 
finger  pass  to  the  glands  in  the  epitrochlear  region, 
and  except  in  the  fulminating  type  these  will  be  found 
enlarged.  From  here  the  infection  is  carried  to  the 
axillary  region  and  thence  to  the  circulation.  The 
lymphatics  from  the  thumb  and  index  finger  will  be 
found  coursing  upon  the  back  and  outer  side  of  the 
forearm  and  wending  their  way  to  the  axillary  glands 
without  the  intervention  of  the  epitrochlear  glands 
(see  p.  304). 

TENOSYNOVITIS 

This  type  of  infection  is  much  more  difficult  to  diag- 
nosticate, and  the  surgeon  is  often  in  doubt  as  to  whether 
he  is  dealing  with  a  hniphangitis  or  tenosynovitis. 


60  DIAGNOSIS  IN  GENERAL 

The  three  cardinal  symptoms  and  signs  are: 

1 .  Exquisite  tenderness  over  the  course  of  the  sheath, 
Hmited  to  the  sheath. 

2.  Flexion  of  the  finger. 

3.  Exquisite  pain  on  extending  the  finger,  most 
marked  at  the  proximal  end. 

These  symptoms  are  seen  to  be  only  a  difference  in 
degree  from  those  found  in  any  infection  of  the  hand, 
but  when  they  are  sought  for  in  an  intelligent  manner 
there  is  not  much  difficulty  in  differentiating  the  con- 
ditions. 

The  size  of  the  primary  wound  is  of  no  importance. 
The  tendon  sheath  may  become  infected  secondarily  to  a 
simple  pin  prick  or  an  extensive  wound.  One  finds  only 
the  cardinal  symptoms  I  have  mentioned,  and  in  addi- 
tion he  may  notice  that  the  abutting  sides  of  the  adja- 
cent fingers  are  swollen,  as  well  as  the  back  of  the  hand. 
The  whole  of  the  involved  finger  is  uniformly  swollen. 
The  whole  hand  is  slightly  tender  and  the  fingers  are 
slightly  flexed.  The  involuntary  expression  of  pain 
which  is  noticed  when  the  tendon  sheath  is  touched 
by  the  examining  finger  leaves  no  doubt  in  the  mind 
of  the  examiner  as  to  the  location  of  the  infection.  The 
greatest  amount  of  tenderness  is  generally  complained 
of  at  the  proximal  end  of  the  finger  sheath  in  the  palm 
at  the  metacarpophalangeal  articulation.  A  difference 
is  readily  seen  between  the  rigidity  in  the  infected 
finger  and  the  simple  flexion  in  the  adjacent  digits. 
So  great  is  this  difference  that  one  is  able  to  diagnos- 
ticate an  extension  into  the  palmar  sheath,  for  instance, 
from  the  little  finger  sheath,  since  the  character  of  the 
flexion  changes  to  the  more  rigid  noted  in  tendon 
sheath  infection.  The  spontaneous  pain,  which  was  at 
first  severe,  grows  less  as  the  edema  develops,  and  may 
delude  the  surgeon  into  believing  that  the  process  is 
subsiding.     The  arm   seems  "to   fall   asleep,"  as   the 


TENOSYNOVITIS  61 

patient  expresses  it.  Paresthesias  with  creeping  and 
itching  sensations  may  be  present,  and,  especially  after 
rupture  of  the  sheath,  the  tenderness  may  subside  to  a 
considerable  degree,  leading  the  surgeon  to  an  early 
erroneous  conclusion. 

An  infection  of  the  sheath  of  the  tendon  in  the  little 
finger  may  be  localized  to  the  finger.  Extensions  to 
other  areas  are  possible,  however.  The  following  are 
the  most  common:  (i)  The  ulnar  bursa;  (2)  the  radial 
bursa;  (3)  the  forearm;  (4)  fascial  spaces  in  the  hand: 
(a)  middle  palmar  space,  {h)  lumbrical  space;  (5) 
osseous  involvement,  middle  phalanx;  (6)  joints, 
proximal  interphalangeal,  wrist;  (7)  rupture  to  the 
surface. 

Extension  to  the  ulnar  bursa  is  often  difficult  to 
diagnosticate.  It  is  marked  by  the  development  of 
edema  in  the  hand,  especially  upon  the  dorsum.  A 
general  fulness  in  the  palm  is  seen,  but  the  palmar 
concavity  is  still  to  be  found.  On  the  flexor  surface 
the  greatest  swelling  is  found  just  proximal  to  the 
annular  ligament.  This  is  not  necessarily  due  to  the 
rupture  of  the  sheath  here,  but  to  the  looseness  of 
the  tissues,  which  permits  of  distention.  This  swelling 
is  accentuated  by  the  non-distensible  annular  ligament 
distal  to  it.  The  swelling  in  the  palm  occurs  at  the 
same  time,  but  is  not  so  conspicuous,  owing  to  the 
palmar  fascia.  This  also  diffuses  the  swelling  so  that  it 
is  not  accurately'  limited  by  the  outline  of  the  ulnar 
bursa.  Moreover,  the  surrounding  edema  tends  to 
confuse  the  picture  (see  pp.  201  and  204). 

The  most  conspicuous  and  valuable  sign  is  the  ex- 
tension of  the  exquisite  tenderness  to  the  area  involved. 
It  should  be  remembered  that  this  is  absent  after  a 
few  days.  The  wrist  becomes  fixed,  the  thumb  shows 
tenderness  to  pressure,  and  particularly  on  passive 
movements  is  the  sensitiveness  noted.    It  is  seen  readily 


62  DIAGNOSIS  IN  GENERAL 

of  how  much  importance  this  latter  symptom  is  in 
diagnosticating  an  extension  to  the  ulnar  bursa  from 
the  little  finger.  We  note  that  while  at  first  the  symp- 
toms are  limited  to  the  little  finger  and  slight  changes 
in  the  ring  finger,  because  of  its  juxtaposition,  all  at 
once  the  thumb  begins  to  show  the  characteristic  signs 
while  the  index  and  middle  fingers  remain  unchanged 
except  for  the  increase  of  pain  on  passive  extension 
explained  above.  This  sensitiveness  of  the  thumb 
may  be  due  either  to  the  juxtaposition  of  the  sacs,  or 
to  a  real  extension  into  its  sheath.  At  first  there  may 
be  a  diffuse  redness  of  the  palm  and  dorsum,  but  it 
rapidly  gives  place  to  a  whitish  or  even  cyanotic  hue. 
Above  the  wrist,  however,  the  tissue  generally  takes  on 
a  marked  red  color,  which  later  becomes  violaceous. 
The  temperature  and  pulse  may  not  be  of  any  diag- 
nostic importance.  Ordinarily  after  the  infection  has 
lasted  a  few  days  and  the  walling-off  process  has  begun, 
the  temperature  is  that  of  the  local  accumulations  of 
pus  and  varies  with  the  freedom  of  drainage.  The 
first  few  days,  however,  the  systemic  absorption  bears 
no  relation  to  the  abscess  formation  and  cannot  be 
relied  upon  for  diagnostic  purposes. 

From  the  bursa  various  extensions  may  take  place 
into  the  fascial  spaces  of  the  hand  and  forearm.  The 
symptoms  and  signs  of  this  extension  will  be  taken  up 
under  the  head  of  "Fascial  Space  Infection"  {vide 
infra;  see  also  p.  204). 

Involvement  of  the  index,  middle,  and  ring  fingers 
presents  the  same  signs  as  the  little  finger.  The  only 
difference  is  that  here  the  paths  of  extension  are  different. 
Besides  the  extension  to  the  surface  at  the  proximal  end, 
involvement  of  the  middle  phalanx  and  the  proximal 
interphalangeal  joint,  the  finger  may  show  extension  to 
the  lumbrical  space  on  either  side,  and  from  here  the 
involvement  of  the  adjacent  tendon  (see  p.  209). 


FASCIAL  SI'ACE  INIECTION  63 

I^Lxtension  to  the  racfial  bursa  is  diagnosLicalcd  as 
following  an  ulnar  bursitis  by  the  increased  swelling 
and  tenderness  in  I  he  thenar  eminence  and  along  the 
sheath.  The  tumefaction  of  the  thenar  area  is  not 
that  of  abscess  in  the  thenar  space  (see  p.  217). 

Diagnosis  of  extension  from  a  tenosynovitis  of  the 
thumb  into  the  radial  bursa,  and  then  into  the  ulnar 
bursa  is  more  difficult.  We  must  depend  ui)on  the 
extension  of  the  tenderness  to  the  area  over  the  radial 
bursa  and  the  tenderness  above  the  anterior  annular 
ligament.  When  the  extension  has  proceeded  over 
into  the  ulnar  bursa  the  diagnosis  is  easier,  since  all 
of  the  fingers  become  painful  to  passive  extension, 
most  markedly  the  little  finger,  with  tenderness  over 
the  area  of  the  ulnar  bursa.  The  tenderness  over 
the  sheath  is  not  always  so  marked  in  secondary 
involvement,  however,  due  possibly  to  the  previously 
developed  edema  (see  p.  213). 

The  pus  from  the  radial  bursa  may  rupture  into 
the  tissues  of  the  forearm,  and  then  the  pus  lies  under 
the  flexor  profundus  tendons  just  as  in  rupture  of  the 
ulnar  bursa  (see  p.  155). 

FASCIAL  SPACE  INFECTION 

Pus  may  be  found  in  various  spaces  in  the  hand  and 
forearm,  as  I  have  already  pointed  out.  This  may  occur 
as  a  primary  infection  or  secondary  to  lymphatic  or 
tendon  sheath  infection,  especially  the  latter.  I  have 
demonstrated  by  injection  and  serial  sections  the  spaces 
in  w^hich  such  accumulation  can  take  place.  These 
w^ell-defined  spaces  are  five  in  number: 

1.  Middle  palmar  space. 

2.  Thenar  space. 

3.  Hypothenar  space. 

4.  Dorsal  subcutaneous  space. 

5.  Dorsal  subaponeurotic  space. 


64  DUGNOSIS  IN  GENERAL 

The  thenar  and  middle  palmar  spaces  are  by  far 
the  most  important  in  the  hand. 

The  forearm  has  certain  spaces  which  are  likely 
to  become  infected.  Briefly,  it  can  be  stated  that  pus 
which  has  extended  from  the  hand  to  the  forearm 
always  lies  under  the  flexor  profundus,  upon  the  prona- 
tor quadratus  and  intermuscular  septum.  It  passes 
upward,  following  the  ulnar  artery,  going  as  high  as  the 
elbow  (see  p.  159). 

Now,  how  shall  we  diagnosticate  an  involvement  of 
these  various  spaces?  First,  upon  the  possibility  of 
extension  from  other  foci.  The  middle  palmar  space 
would  receive  infection  by  extension  from  the  middle 
finger,  ring  finger,  little  finger,  also  from  the  ulnar  bursa 
and  localized  infections  in  the  lumbrical  canals  be- 
tween the  heads  of  the  metacarpals.  Again,  it  may  be 
involved  by  direct  implantation  or  through  osteo- 
myelitis of  the  middle  and  ring  metacarpals.  It  is 
possible  for  a  thenar  space  abscess  to  rupture  into  the 
middle  palmar  space  (pp.  168  and  216). 

The  thenar  space  might  receive  the  infection  from 
the  index  finger  or  thumb,  or  by  direct  implantation, 
or  by  osteomyelitis  of  the  index  or  thumb  metacarpals, 
and  finally,  it  would  be  possible  for  the  space  to  become 
involved  secondarily  to  the  middle  palmar  space 
(see  pp.   168  and  216). 

The  forearm  may  be  involved  by  extension  along  the 
connective-tissue  spaces  back  of  the  tendons  or  by 
rupture  from  either  the  ulnar  or  radial  bursa  (see  pp. 
154  and  383).  The  source  of  the  involvement  of  the 
other  spaces  can  be  readily  surmised  (see  pp.  168 
and  215). 

When  the  middle  palmar  space  is  involved  we  notice 
that  whereas  earlier  there  had  been  a  fulness  in  the 
palm  without  loss  of  the  concavity;  now  the  concavity 
begins  to  be  lost,  and  as  the  process  becomes  marked, 


F.ISCI.IL  S/'.ICK  l\IECTI()\  65 

a  slight  bulging  of  the  palm  is  noticeable  in  spite  of 
the  palmar  fascia.  The  correlation  of  this  with  ten- 
derness is  of  especial  value.  Early,  before  the  swelling 
becomes  marked,  the  tenderness  is  exquisite  and  limited 
by  the  outlines  of  the  middle  palmar  space;  but  as  the 
swelling  increases,  the  tenderness  and  especiall>'  the 
spontaneous  pain  grow  less.  There  is  generally  more 
or  less  extension  along  the  lumbrical  canals,  so  that  the 
swelling  of  the  area  between  the  heads  of  the  meta- 
carpals adds  to  the  general  picture.  The  area  may  be 
red,  but  generally  it  is  pallid.  With  this  there  is  found 
the  flexion  of  the  fingers  due  to  the  juxtaposition  of 
the  tendons  to  this  area.  They  are  held  rigidly  flexed, 
decreasing  in  rigidity  from  the  little  finger  to  the  index 
finger.  The  latter  may  have  considerable  voluntary 
motion.  If  the  pus  has  extended  along  the  lumbrical 
canals  to  the  base  of  the  fingers,  there  may  be  swelling  and 
induration  in  the  loose  tissue  of  the  web,  and  an  accu- 
mulation of  pus  may  be  found  to  have  extended  to  the 
dorsum  between  the  heads  of  the  proximal  phalanges. 
The  relation  of  the  swelling  in  the  palm  to  that  in  the 
thenar  area  is  of  great  importance.  In  involvement 
of  the  middle  palmar  space  there  is  an  associated 
sw^elling  of  the  thenar  space  of  almost  the  same  degree 
as  that  of  the  middle  palmar  space,  but  this  is  due  to 
edema  (see  pp.  216  and  225).'  When  the  thenar  space 
becomes  involved  the  swelling  is  out  of  all  proportion 
to  that  of  the  palm  if  it  be  involved.  There  is  the 
induration  of  infection  rather  than  the  softness  of 
edema.  The  thenar  space  will  look  as  if  a  balloon 
had  been  inserted  into  the  area  and  blown  up  to  its 
full  capacity.  I  know  of  no  clinical  picture  in  surgery 
that  is  more  characteristic  than  this  of  thenar  space 
infection,  and  having  once  seen  it  one  cannot  forget 
it.  Besides  the  ballooning  out  of  the  thenar  area,  the 
metacarpal  of  the  thumb  is  pushed  awa\-  from  the  hand  ; 
5 


66  DIAGNOSIS  IN  GENERAL 

the  flexion  of  the  distal  phalanx  becomes  more  marked 
though  lacking  the  rigidity  found  in  involvement  of 
the  tendon  sheath  of  the  flexor  longus  pollicis.  This 
infection  of  the  thenar  space  may  be  primary  and 
isolated  or  secondary  to  a  middle  palmar  infection  (see 
pp.  i68  and  216). 

The  edema  upon  the  back  of  the  hand  is  always 
present  and  the  swelling  much  greater,  of  course,  than 
in  the  palm,  even  though  that  be  the  site  of  the  pus. 
It  is  extremely  uncommon  to  find  any  pus  upon  the 
dorsum  unless  there  has  been  a  lymphatic  infection  or 
the  pus  has  extended,  as  already  described,  between 
the  metacarpals  of  the  index  finger  and  thumb  from 
the  thenar  space,  or  between  the  heads  of  the  proximal 
phalanges.  We  should  bear  in  mind  that  edema  gives 
rise  to  a  soft  pitting,  while  if  pus  be  present  induration 
can  always  be  felt.  If  this  fact  is  borne  in  mind  many 
embarrassing  mistakes  will  be  avoided.  I  think  that  in 
three-fourths  of  the  hands  I  see  in  which  treatment 
has  been  instituted  a  number  of  unnecessary  and 
improper  incisions  are  found  upon  the  dorsum  (Fig.  74). 

The  infection  may  spread  from  either  space  to  the 
forearm,  or  this  may  be  involved  from  a  tenosynovitis 
of  the  ulnar  or  radial  bursa.  As  has  been  pointed  out, 
the  pus  in  these  cases  passes  between  the  pronator 
quadratus  and  the  flexor  profundus  to  the  area  between 
the  latter  and  the  interosseous  membrane,  and  at  about 
the  middle  of  the  area  it  passes  more  superficially  and 
to  the  ulnar  side  along  the  ulnar  artery  and  nerve. 
This  extension  is  characterized  by  a  brawny  induration 
that  should  not  be  confused  with  the  softness  of  an 
edema.  No  fluctuation  should  be  expected,  since  the 
accumulation  lies  too  deeply.  If  the  primary  source 
is  the  ulnar  or  radial  bursa,  this  extension  is  marked 
by  the  loss  of  the  relative  swelling  immediately  above 
the  annular  ligament,  due  to  the  distended  upper  end 


FASCIAL  SPACE  INFECTION  07 

of  the  sheath.  This  swelhng  is  not  any  less,  but  that 
of  the  arm  is  greater.  The  tenderness  may  become  less, 
so  it  cannot  be  depended  upon  as  a  symptom.  The 
redness  is  generally  greater,  and  spontaneous  pain, 
wliile  at  first  marked,  rapidly  subsides.  At  this  time 
some  pus  may  accumulate  subcutaneously  above  the 
wrist  and  lead  to  the  supposition  that  there  is  no  pus 
under  the  tendons.  Thus  valuable  time  is  lost  (see 
pp.  208  and  383). 

Involvement  of  the  hypothenar  space  can  often  be 
prognosticated  from  the  site  of  the  primary  injury, 
while  the  relative  lack  of  swelling  in  the  palm  and 
fingers,  with  absence  of  involvement  of  the  tendons, 
combined  with  the  ordinary  symptoms  of  abscess, 
leads  us  to  an  easy  diagnosis.  Fortunately,  the  hypo- 
thenar area  is  so  separated  from  the  remainder  of  the 
hand  that  it  is  not  frequently  involved  secondarily 
to  palmar  infection  (see  pp.  146  and  176). 

An  infection  localized  under  the  subaponeurotic 
fascia  to  the  exclusion  of  the  subcutaneous  tissue  may 
be  difficult  of  differential  diagnosis.  However,  we 
are  aided  materially  if  we  remember  the  character 
of  the  primary  injur}^  the  methods  of  extension  to 
this  space  already  mentioned,  and  the  local  evidences 
of  infection  upon  the  dorsum,  with  the  pitting  edema 
of  the  subcutaneous  tissue,  yet  lacking  the  brawny 
induration  and  localized  tenderness  of  a  subcutaneous 
abscess  (see  pp.  146  and  176). 

We  may  be  in  doubt  as  to  whether  we  are  dealing 
with  a  tenosynovitis  of  the  ulnar  or  radial  bursa  or  a 
rheumatism  of  the  wrist.  I  have  seen  several  such 
cases,  and  in  one  case  it  was  difficult  to  determine 
whether  the  patient  was  suffering  from  a  gonorrheal 
rheumatism  of  the  proximal  interphalangeal  joint  of  a 
finger  or  a  gonorrheal  tenosynovitis  with  secondary 
involvement  of  the  joint.     The  latter  assumption  was 


68  DIAGNOSIS  IN  GENERAL 

later  found  to  be  the  condition  present.  In  those  cases 
presenting  an  apparently  spontaneous  development  of 
an  inflammation  at  the  wrist,  the  diagnosis  may  be  most 
dijfhcult  in  spite  of  the  ease  with  which  a  theoretical 
differential  diagnosis  is  made.  Here  again,  however, 
the  localized  tenderness  over  the  sheath  and  pain  on 
extension  of  the  finger  are  of  the  greatest  importance. 
Moreover,  these  cases  are  always  virulent  and  extend 
rapidly,  so  that  if  it  be  a  tenosynovitis  the  hand  grows 
rapidly  worse.  In  a  rheumatism  there  is  as  much 
pain  on  the  dorsal  as  on  the  volar  surface,  the  swelling 
involves  the  wrist  more  than  the  hand,  fingers,  or 
forearm,  and  other  joints  may  be  involved.  The 
presence  of  a  gonorrhea  does  not  aid  us  materially, 
since  either  condition  may  follow. 

DIAGNOSIS  OF  EXTENSIONS  FROM  VARIOUS  SITES 

The  diagnosis  of  the  extensions  from  various  sites 
is  of  the  greatest  importance  from  a  therapeutic  stand- 
point. I  have  worked  out  these  possibilities  by  both 
experimental  and  clinical  observations.  The  present 
chapter  is  too  brief  to  allow  a  full  discussion.  I  shall, 
however,  append  a  tabulation,  with  references  attached, 
denoting  where  a  complete  discussion  of  each  subject 
can  be  found. 

If  the  infection  originates  in  the  thumb,  for  possible 
extensions  see  p.  191. 

If  the  infection  originates  in  the  index  finger,  for 
possible  extensions  see  p.  185. 

If  the  infection  originates  in  the  middle  finger,  for 
possible  extensions  see  p.  191. 

If  the  infection  originates  in  the  ring  finger,  for 
possible  extensions  see  p.  192. 

If  the  infection  originates  in  the  little  finger,  for 
possible  extensions  see  p.  193. 


DIAGNOSIS  or   F.XTEXSIOXS   IkOM    I    IKIOl  S  SITES     (i!» 

If  the  palmar  sj)ac-e  is  iiivt^lvcd,  lor  possible  exten- 
sions see  pp.  143  and  177. 

If  the  thenar  space  is  involved,  for  possible  exten- 
sions see  pp.  144  and  183. 

If  the  forearm  is  involved,  for  possible  extensions  see 
pp.  159  and  384. 

If  the  ulnar  bursa  is  involved,  for  possible  exten- 
sions see  pp.  120  and  204. 

If  the  radial  bursa  is  involved,  for  possible  extensions 
see  pp.  125  and  213. 


CHAPTER    VI 
GENERAL   PRINCIPLES   OF  TREATMENT 

It  is  not  the  intention  here  to  discuss  in  detail  the 
treatment  of  the  various  types  of  infections.  Specific 
directions  for  dealing  with  individual  cases  will  be 
discussed  in  the  chapters  devoted  to  the  different 
types.  It  is  proper,  however,  to  deal  with  the  general 
principles  underlying  the  various  procedures  which 
might  be  scattered  in  the  succeeding  chapters. 

The  early  treatment  in  any  case  has  for  its  purpose 
the  walling  off  of  the  infection,  or  its  removal  by 
phagocytic  action. 

Rest. — Rest  is  one  of  the  essential  factors,  at  least 
in  a  negative  sense.  The  extremity  affected  should 
always  be  so  fixed  that  movement,  either  of  the  whole 
or  muscular  action  of  a  part,  is  impossible,  since  it  is 
well  known  that  the  lymphatic  streams  are  aided 
materially  in  their  return  flow  by  muscular  action. 
It  will  undoubtedly  relieve  the  patient  somewhat  of 
the  throbbing  pain  to  have  the  hand  elevated  after 
the  von  Volkmann  method,  but  beyond  this  I  cannot 
feel  that  the  procedure  is  of  great  therapeutic  value. 

Positive  factors  designed  to  increase  phagocytic 
action  are  still  subject  to  discussion,  in  spite  of  the 
extensive  contributions  in  support  of  this  or  that  pro- 
cedure. They  may  be  classified  as  systemic  and  local. 
The  local  again  are  divided  into  the  results  of  active 
hyperemia  and  of  passive  hyperemia. 

Drugs. — The  systemic  use  of  drugs,  such  as  nucleic 
acid,  etc.,  to  increase  leukocytosis,  has  never  been 
followed  by  such  marked  and  positive  results  as  to 


r.lSSiri:   IIYPIiREMLI  71 

prove  beyond  question  the  advisabiiit>'  of  their  use, 
and  all,  so  far  as  known,  may  ultimately  be  discarded, 
as  was  turpentine,  which  preceded  them.  They  have 
never  given  any  results  in  my  hands.  We  are  not  now 
discussing  the  applicability  of  drugs  and  sera  in  sys- 
temic infections.  They  will  be  taken  u\)  under  that 
heading  later  (see  pp.  356  and  357). 

Passive  Hyperemia. — Among  the  local  procedures 
those  producing  passive  hyperemia  (Bier)  have  re- 
ceived the  greatest  attention  in  later  years.  While 
much  of  an  enthusiastic  nature  has  been  written  in 
favor  of  this  method,  it  is  probable  that  the  American 
surgeons  have  not  secured  the  results  claimed  for  it 
by  its  German  supporters.  It  is  not  the  province  of 
such  a  contribution  as  this  to  review  the  subject,  with 
a  discussion  of  the  various  theories  as  to  the  changes 
in  the  blood;  the  lessened  resistance  as  claimed  by  some, 
and  the  raised  opsonic  index  as  maintained  by  others. 
My  personal  opinion  has  become  quite  settled  as  to 
its  value  in  acute  infections.  I  have  found  its  chief 
value  in  three  conditions: 

1.  In  those  conditions  in  which  I  wish  to  prevent 
the  rapid  absorption  of  toxins  into  the  circulating 
blood,  as,  for  instance,  in  an  acute  lymphangitis  (see 
PP-  353  and  354),  or  immediately  after  incising  virulent 
abscesses  of  the  hand  and  arm  where  a  marked  con- 
striction will  reverse  the  lymph  stream  and  tend  to 
wash  the  toxins  out  into  the  wound,  preventing  ab- 
sorption (see  pp.  22^  and  279). 

2.  In  those  cases  in  which  the  process  has  become 
semichronic  with  a  low  grade  of  infection  (see  pp.  22S 
and  435). 

3.  In  the  case  of  localized  abscesses  which  do  not 
drain  freely.  Here  the  suction  cup  is  of  especial  value 
(seep.  435). 

Beyond  these  conditions  I  must  say  I  look  upon  it  as 


72  GENERAL  PRINCIPLES  OF  TREATMENT 

a  possible  adjuvant  in  the  treatment,  but  never  as  the 
primary  factor.  It  follows,  therefore,  that  early  in  the 
course  of  an  infection,  if  we  suspect  the  process  to  be 
particularly  virulent,  a  bandage  may  be  applied  to  the 
arm  after  the  method  described  on  pp.  227  and  353. 
Any  other  method  is  painful  and  may  even  be  harmful. 
In  the  ordinary  cases  I  have  contented  myself  with 
other  means,  namely,  hot,  moist  dressings,  the  use  of 
which  I  believe  rests  upon  a  more  rational  basis.  Klapp 
has  emphasized  the  value  of  suction  cups  used  over  a 
localized  infection.  He  has  devised  various  types  to 
fit  various  areas.  Their  value  in  certain  conditions 
cannot  be  gainsaid,  particularly  in  those  cases  which 
would  be  classified  in  the  second  and  third  groups  above. 
Hot  Moist  Dressings. — These  are  in  common  used 
by  all,  and  have  proved  beneficial  in  many  cases.  The 
most  common  form  in  which  they  are  applied  is  that 
of  the  saturated  hot  boric  acid  solution,  although  many 
other  medicaments  are  employed,  such  as  potassium 
permanganate,  alcohol,  bichloride,  etc.  The  solution 
of  hot  boric  acid,  in  my  opinion,  depends  for  its  effi- 
ciency largely  upon  the  moist  heat,  although  scientific 
evidence  is  not  wanting  that  its  chemical  action  may 
be  of  some  value.  In  this  connection  Dr.  E.  H. 
Ochsner  reports  that  Professor  Kakenberg,  at  the 
University  of  Wisconsin,  conducted  a  series  of  examina- 
tions demonstrating  the  presence  of  a  small  amount 
of  boric  acid — o.oi  to  0.03  per  cent. — in  urine  voided 
after  hot  applications  of  a  saturated  solution  of  boric 
acid  in  water,  3  parts,  and  95  per  cent,  alcohol,  i  part. 
This  is  not  the  occasion  to  discuss  the  question  as  to  the 
bactericidal  effect  of  boric  acid,  especially  in  small 
percentages.  Other  investigators  have  maintained  that 
a  large  percentage  is  found  in  the  skin  and  subcutaneous 
tissue.  The  dressings  may  be  applied  as  follows:  The 
saturated  solution  is  boiled  and  then  set  aside,  and,  as 


HOT  MOIST  DRJ'.SSINGS  !'•'> 

it  is  desired,  it  is  heated  to  as  great  a  heat  as  can  be 
borne  by  the  bare  forearm  of  the  attendant.  Greater 
heat,  as  demanded  by  some,  is  not  needful.  The  patient 
should  not  be  left  to  decide  "if  he  can  stand  it,"  since 
the  infected  hand  is  often  very  insensitive  to  super- 
ficial pain,  and  the  inadvertent  application  of  the  ex- 
cessive heat  may  lead  to  blisters  which  will  be  annoying 
and  prolong  convalescence.  After  the  desired  tempera- 
ture is  secured  a  sterile  towel  is  unfolded  and  the  dress- 
ings dropped  into  this,  which  is  now  immersed  at  its 
middle  in  the  water.  The  dressings  are  wrung  dry  by 
turning  the  two  dry  ends  in  opposite  directions,  thus 
securing  the  dressings  properly  saturated  and  wrung 
out,  but  still  sterile.  The  dressing  is  now  applied 
widely,  covering  the  entire  infected  area,  going  proxi- 
mally  some  inches.  Fear  rather  that  your  dressing  may 
be  too  small  than  too  voluminous.  The  whole  is  covered 
by  some  impervious  material,  such  as  paper  saturated 
with  paraffin  or  sheet  gutta-percha.  This  should  be 
covered  by  a  layer  of  cotton  followed  by  a  bandage. 
Provision  should  be  made  at  the  time  of  dressing  for 
subsequent  applications  of  the  solution  by  making  a 
hole  or  two  through  the  outside  covering  down  to  the 
dressing.  Through  these  openings  the  boric  acid 
solution  should  be  poured  every  tw^o  hours,  and  the 
hand  dressed  as  frequently  as  necessary. 

Too  often  we  see  the  hot  boric  acid  continued  for 
several  days.  It  is  not  only  useless  but  harmful  to 
continue  this  treatment  after  the  process  is  once  under 
control,  since  it  tends  to  favor  congestion  and  round- 
cell  exudation,  which  if  long  continued  produces  a 
soggy,  infiltrated  hand,  in  which  absorption  is  slow,  and 
as  a  consequence  the  ravages  of  the  disease  are  slowly 
repaired  and  fibrinous  ankylosis  of  joints,  adhesions 
of  the  tendons,  shrinking  of  muscles,  and  fibrosis  in 
all  the  various  structures  are  favored. 


74  GENERAL  PRINCIPLES  OF  TREATMENT 

As  soon  as  the  process  has  subsided  it  may  be  treated 
in  various  ways,  according  to  the  condition.  In  the 
presence  of  congestion,  a  dressing  saturated  with  a 
weak  solution  of  alcohol  will  aid  in  the  dehydration. 
If  there  is  a  foul  discharge,  a  i  to  2000  potassium 
permanganate  dressing  is  advisable.  If  there  are  many 
raw  surfaces  requiring  dressing,  the  gauze  may  be  satu- 
rated with  vaseline,  which  permits  of  painless  dressing 
and  does  not  retard  drainage.  Against  alcohol  may  be 
urged  with  justice  its  inflammability,  so  that  it  should 
always  be  used  with  care.  One  case  came  to  my  notice 
in  which  the  patient  was  severely  burned  through  its 
use. 

Prophylactic  Incision. — One  constantly  meets 
cases  in  which  the  patient  has  been  subjected  to  inci- 
sion at  some  swollen  or  tender  area,  under  the  assump- 
tion that  if  there  is  not  pus  there  the  "drainage  will 
do  good  anyway."  Such  incisions  are  always  ill- 
advised,  since  they  nearly  always  do  more  harm  than 
good.  A  general  rule  should  be  laid  down  not  to  incise 
unless  the  surgeon  has  an  accurate  appreciation  of  the 
condition  and  an  absolute  diagnosis  made.  In  general, 
one  may  say  that  incision  in  lymphatic  infections 
should  be  made  as  a  last  resort  or  because  of  secondary 
complications  (see  pp.  354  and  361).  Tenosynovitis 
should  be  treated  by  drainage  as  soon  as  the  diagnosis 
is  made  (see  pp.  250  and  251).  Abscesses  of  the  fascial 
spaces  are  never  so  urgent  as  to  demand  operation 
before  one  is  sure  of  the  diagnosis.  These  rules  are 
urged  most  emphatically,  since  I  see  in  consultation 
^ully  as  many  cases  in  which  the  incision  made  has 
been  ill-advised  or  unnecessary  as  I  do  those  in  which 
further  surgical  work  is  indicated. 

When  incision  has  been  decided  upon  certain  rules 
are  imperative  in  the  severe  case.  The  operation  should 
be  done  in  a  bloodless  field.     I  preferably  use  a  Martin 


DRAINAGE  75 

bandaiic,  which  is  ai)j)hcd  from  the  elbow  to  the 
shoulder.  After  the  oi)eration  is  concluded  the  band- 
age is  loosened  slightly,  just  enough  to  allow  circulation, 
but  still  tight  enough  to  prevent  rapid  absorption. 
In  fact,  I  attempt  to  produce  a  Bier's  hyperemia. 
This  is  done  with  the  hope  of  preventing  the  rapid 
absorption  of  toxins.  In  a  patient  who  is  severely 
ill  such  rapid  absorption  may  take  place  as  to  over- 
whelm the  system  before  it  has  an  opportunity  to 
develop  antitoxins,  while  if  the  bandage  is  removed 
through  the  course  of  twenty-four  hours  the  system 
may  have  an  opportunity  to  develop  antitoxins  and 
ward  off  a  systemic  infection  that  might  ultimately 
lead  to  death.  Again,  the  patient  should  always  be 
anesthetized.  Nitrous  oxide  is  the  anesthetic  of  choice, 
owing  to  its  non-toxic  action.  This  gives  time  for 
carefully  placed  and  adequate  incisions.  The  surgeon 
should  always  convince  himself  before  allowing  the 
patient  to  awaken  that  he  has  done  the  work  thor- 
oughly so  that  the  operation  will  not  have  to  be  re- 
peated upon  subsequent  days.  This  cannot  be  done 
under  local  anesthesia.  Moreover,  the  hypodermic 
injection  of  tissue  about  an  infected  area  cannot  be 
done  without  danger  of  causing  a  spread  either  locally 
or  systematically. 

Drainage. — Drainage  of  wounds  by  means  of 
gauze,  tubes,  etc.,  is  not  of  the  importance  attributed 
to  it  by  some.  The  essential  factor  is  to  make  the 
incision  at  the  right  place  and  of  adequate  size.  If  this 
is  done,  drainage  strips  will  be  not  only  unnecessary 
after  the  first  forty-eight  hours,  but  often  positively 
detrimental  to  recovery.  After  incision  it  is  my  custom 
to  use  either  plain  gauze,  gauze  saturated  with  vase- 
line, or  gutta-percha  strips.  The  former  is  used  only 
when  there  is  venous  oozing  and  we  desire  to  stop  it 
by  favoring  coagulation.     We  must  never  expect  it 


76  GENERAL  PRINCIPLES  OF  TREATMENT 

to  do  more  than  this,  and  keep  the  edges  of  the  wound 
separated,  for  the  plain  gauze  mesh  is  soon  filled  with 
pus  and  coagulated  serum,  which  acts  as  an  effectual 
bar  to  drainage.  Where  there  is  no  bleeding,  gauze 
strips  thoroughly  saturated  with  vaseline  or  gutta- 
percha strips  are  used.  These  secure  adequate  drainage, 
and  can  be  removed  without  pain.  They  are  left  in 
for  twenty-four  to  forty-eight  hours;  if  left  in  longer 
they  prolong  the  suppuration.  It  has  happened  to 
every  surgeon  that  he  sees  cases  in  which  the  wound 
has  been  kept  open  for  weeks  by  ill-advised  drainage 
material.  Rubber  tubes  are  never  used,  since  they  favor 
tissue  necrosis  and  are  not  any  more  satisfactory  for 
drainage  than  gutta-percha  strips. 

It  has  been  suggested  by  some  that  in  order  to 
prevent  rapid  absorption  and  danger  of  generalized 
infection,  it  would  be  advisable  to  open  abscesses  by 
the  cautery,  and  again  others  have  suggested  painting 
the  cut  edges  with  some  solution  of  iodine.  The 
advisability  of  this  procedure  is  open  to  discussion, 
since  it  surely  should  not  be  used  unless  the  abscess 
is  thoroughly  walled  off,  in  which  case  it  is  possible 
to  conceive  of  this  procedure  being  pathologically 
sound.  In  a  majority  of  cases,  however,  bacteria  and 
toxins  in  the  wall  are  thus  sealed  up  and  serum  drain- 
age by  the  method  I  have  suggested  is  prevented 
(see  pp.  228  and  276).  Thus  the  patient  is  in  greater 
danger  of  systemic  infection  or  prolonged  local  dis- 
turbance. It  is  my  personal  belief  that  any  procedure 
which  impairs  the  vitality  of  tissue  cell  life,  thus 
reducing  its  resistance  and  reparative  powers,  will  be 
discarded  in  the  end. 

The  common  habit  of  pressing  and  squeezing  wounds 
with  the  purpose  of  forcing  out  the  contained  pus 
cannot  be  too  severely  condemned.  It  is  both  un- 
necessary and  harmful.     If  adequate  incision  is  made, 


M/ISSAGE  77 

[hv  i)iis  five  in  the  abscess  will  drain  out,  and  if  it  is 
in  the  layers  of  fascia  adjacent  to  the  wound,  pressure 
is  just  as  likely  to  force  it  farther  into  the  tissue  as 
into  the  abscess  cavity.  If  the  opening  is  small  and 
drainage  inadequate  because  of  the  thickness  of  the 
pus  the  wound  should  be  opened  more  widely,  or  the 
pus  removed  by  the  Klapp  suction  cup.  If  the  open- 
ing is  plugged  by  seminecrotic  connective  tissue,  it 
may  be  removed  by  the  forceps,  never  with  a  sharp 
curette.  To  repeat,  the  pressure  and  squeezing  tend 
to  disseminate  the  infection  throughout  the  surround- 
ing tissue  and  even  produce  systemic  infection  or 
dislodge  septic  thrombi. 

After  almost  all  incisions  in  virulent  cases  there  is 
severe  local  reaction,  causing  more  swelling  in  the  first 
twenty-four  to  thirty-six  hours.  At  the  end  of  that 
time,  if  the  process  has  been  properly  drained,  the 
swelling  should  begin  to  subside. 

Stimulation  of  Excretion. — The  excretions  should 
be  stimulated,  particularly  by  the  introduction  of 
large  amounts  of  water  into  the  system.  This  may  be 
done  subcutaneously  by  rectum  or  by  mouth,  accord- 
ing to  the  conditions  to  be  met.  In  the  severe  toxe- 
mias I  also  use  alcohol  and  peptonized  foods  for  the 
reasons  enumerated  later  (see  p.  356). 

Massage. — The  early  use  of  massage  and  passive 
motion  is  one  of  the  essentials  in  the  production  of 
functionating  hands.  Its  use  is  particularly  urged  in 
tendon-sheath  infection  (see  p.  278). 


SECTION    1 

THE   ANATOMY    OF   THE    HAND    AND    FOREARM, 

WITH   ESPECIAL   CONSIDERATION  OF   ITS 

RELATION  TO  INFECTIONS  OF  THE 

SYNOVIAL   SHEATHS  AND 

FASCIAL  SPACES 


CHAPTER   VII 

METHODS  OF  STUDY  IN  GENERAL:   STUDY  OF  SERIAL 

CROSS-SECTIONS  OF  THE  HAND,  WITH  PARTICULAR 

RELATION  TO  THE  FASCIAL  SPACES 

Upon  beginning  the  study  of  infections  of  the  hand 
it  was  reahzed  immediately  that  our  general  knowledge 
of  the  anatomy  was  entirely  inadequate  when  we  came 
to  apply  it  to  specific  conditions.  The  first  problem, 
therefore,  with  which  we  had  to  deal  was  a  thorough 
study  of  the  anatomy  carried  out  entirely  in  relation 
to  this  question.  As  the  work  progressed,  its  immense 
value  from  a  diagnostic  and  therapeutic  standpoint 
began  to  be  realized.  The  reasons  for  many  failures 
in  treatment  were  seen.  The  diagnosis  was  placed 
upon  a  firm  basis.  We  are  firmly  convinced  that  any- 
one who  wishes  to  master  the  proper  steps  in  diagnosis 
and  treatment  must  follow  step  by  step  the  unfolding 
of  the  anatomical  picture  as  we  shall  try  to  present 
it  in  the  subsequent  pages.  It  will  be  discussed  in 
the  followinu  manner: 


80  METHODS  OF  STUDY  IN  GENERAL 

Anatomy  of  the  Hand  and  Forearm,  with  Surgical 
Deductions 

A.  Anatomy  of  the  hand. 

I.   Methods  of  study. 
II.  Study  of  serial  cross-sections,  with  particu- 
lar relation  to  fascial  spaces. 
III.  Study  of  the  tendon  sheaths  in  general. 
IV.  Study   of   the   fascial   spaces   and   tendon 
sheaths  by  means  of  experimental  injec- 
tions. 
V.  Study  of  x-ray  pictures  of  injected  hands. 
VI.  Study  of  the  embryology. 

B.  Anatomy  of  forearm. 

I.  Anatomy  in  general. 
II.  Study  of  serial  cross-sections. 
III.  Study  by  means  of  injection  of  the  con- 
nective-tissue spaces. 

METHODS  OF  STUDY 

I.  With  the  object  of  securing  a  tentative  picture 
of  the  spaces  and  their  relation  to  the  tendon  sheaths 
in  particular  and  other  structures  in  general,  a  freshly 
amputated  cadaver  hand  was  hardened  in  formalin 
and  cross-sections  made,  beginning  at  the  middle 
joints  of  the  fingers,  and  cutting  sections  about  one 
centimeter  in  width,  going  as  high  as  the  elbow.  The 
fascial  layers  were  then  teased  out  and  their  relations 
to  the  muscles,  bones,  tendons,  nerves,  and  blood- 
vessels determined.  The  prolongations  of  the  various 
spaces  were  followed  up,  each  space  and  each  tendon 
sheath  being  followed  from  one  section  to  another; 
thus,  their  limitations  were  determined  and  the  rela- 
tion of  the  various  adjacent  structures  noted.  The 
specimen  chosen  was  one  with  but  little  fat  (Fig.  i8). 


METHODS  OF  STUDY 


81 


The  same  j^rocess  was  carried  out  in  a  fresh  cadaver 
liaiid  in  which  the  vessels  WTrc  injected  and  the  sections 
cut  while  the  liand  was  frozen.  Sections  were  made  of 
a  thii'd  hand  at  right  angles  to  the  metacarpal  bone  of 
[\\c  ihunil),  since  it  w'as  found  tliat  the  findings  in  the 
thenar  area  were  somewhat  confusing.  This  hand  also 
was  frozen,  and,  like  the  first  and  second,  without 
nuich  fat.  ]3y  these  sections  a  fairly  definite  idea  of 
the  spaces  was  secured. 

Fig.  1 8 


Drawing  made  from  specimen  showing  sites  of  the  various  sections  taken 
through  the  hand. 

2.  To  corroborate  the  findings  above,  as  well  as  to 
determine  their  exact  limitations,  injections  were  made 
into  the  various  fascial  spaces,  by  various  channels, 
and  with  varying  degrees  of  force.  This  determined 
not  alone  the  positions  and  relations  of  the  pockets, 
but  also  b}-  what  channels  pus  cc^ukl  reach  them  and 


82  METHODS  OF  STUDY  IN  GENER'AL 

where  it  would  extend  if  it  broke  through  the  walls 
of  the  closed  fascial  spaces.  By  this  we  also  determined 
the  course  pus  would  pursue  when  it  ruptured  from  the 
tendon  sheaths,  and  thus  fixed  the  relation  of  the  tendon 
sheath  infections  to  fascial  space  infections.  The 
findings  were  very  uniform  and  satisfactory,  with  the 
exception  of  three  or  four  which  did  not  reach  the 
spaces  intended.  The  material  used  was  such  as  that 
ordinarily  found  in  the  dissecting  room;  hence,  while 
the  part  was  always  well  preserved,  in  som.e  cases  the 
material  was  more  friable  than  in  others,  and,  therefore, 
rupture  from  the  space  was  more  likely  to  occur.  How- 
ever, this  does  not  interfere  with  the  deductions,  since 
the  changes  present  were,  in  a  measure,  comparable 
to  those  found  in  inflammatory  processes.  Moreover, 
no  matter  whether  the  tissue  was  fresh  or  preserved, 
the  findings  were  the  same,  so  we  may  feel  sure  that 
the  results  are  to  be  depended  upon.  * 

The  fascial  spaces  of  56  hands  and  forearms  were 
injected  from  various  sites  by  plaster  of  Paris,  which 
had  been  rubbed  up  with  glycerin  and  diluted  with 
water.  It  was  injected  by  means  of  a  hand  pump 
through  a  cannula,  which  was  inserted  at  various 
points,  as  will  be  noted  later.  As  the  hands  were 
dissected,  the  location  and  paths  of  extension  of  the 
masses  were  noted.  In  those  cases  injected  with 
moderate  force  a  pressure  of  4  to  8  pounds  was  used, 
and  where  forcible  injection  is  noted,  25  to  35  pounds. 

3.  Several  hands  were  injected  as  above,  except  that 
the  injection  mass  was  impregnated  with  red  lead. 
A'-ray  pictures  were  taken.  This  showed  the  relation 
of  the  theoretical  pus  accumulations  to  the  bones  and 
bloodvessels,  the  latter  having  been  injected  with  the 
same  mass.  Again,  in  other  hands,  injections  of  vari- 
ous spaces  were  made,  concomitant  with  injections  of 
the  synovial  sheaths,  to  show  their  relation  and  the 


.-/  STUDY  OF  SERI.ll.  CROSS-^SKCTIOXS  S3 

projKT  site  for  operations  designed  to  open  the  former 
wilhout  injury  to  the  latter. 

4.  After  this  work  had  been  done  a  study  of  the 
enil)r\ oloLiA  was  made,  with  a  view  of  determining 
whether  or  not  there  was  any  relation  between  the 
anatomical  i)eriiliarities  of  the  spaces  and  the  embryo- 
logical  development. 

5.  The  clinical  cases  which  came  under  observation 
were  observed  very  carefully  to  see  if  the  real  pathology 
corresix:)nded  with  the  anatomical  demonstration.  Bac- 
teriological studies  of  all  cases  were  made,  that  we 
miglit  investigate  the  relation  between  the  variety  of 
germs  present  and  the  tendency  to  spread. 

A  STUDY  OF  SERIAL  CROSS-SECTIONS,  WITH  PARTICULAR 
RELATION  TO  THE  FASCIAL  SPACES 

That  we  ma\'  follow  the  stud}'  of  the  serial  cross- 
sections  with  more  understanding,  the  following  facts 
should  l)e  n(^tcd:  It  is  known  that  five  spaces  may  be 
found  in  the  hand;  the  information  about  them,  how- 
e\-er.  lias  been  \-er\-  indefinite.  The  result  of  our  study 
shows  tliat  upon  the  i)alniar  surface  we  ha\'e  three 
distinct  chambers,  not  communicating  in  any  way 
with  each  other,  and  to  these  are  given  the  names 
thenar,  hypothenar.  and  middle  palmar  spaces  re- 
specti\eh-.  (Certain  channels  will  be  found  which  lead 
directly  into  them.  Certain  structures  along  which 
pus  can  pass  will  be  noted  lying  in  juxtaposition. 
Again,  minor  anatomical  chambers  will  be  noted;  these, 
howe\er,  need  little  or  no  consideration  from  a  surgical 
standpoint,  since  they  are  unimportant,  not  likely  to 
become  infected  separateh',  and  if  the\-  do,  the>-  will 
rupture  into  one  of  the  larger  pockets. 

Upon  the  dorsum  two  areas  will  be  found,  in  each  of 
whicli  pus  can  accunuilate  to  the  exclusion  of  the  other. 


84 


METHODS  OF  STUDY  IN  GENERAL 


To  these  are  given  the  names  dorsal  subcutaneous 
space  and  dorsal  subaponeurotic  space.  We  shall  find 
that  while  the  pus  may  lie  at  various  levels  in  the 
subcutaneous  tissue,  from  an  anatomical  standpoint, 
yet  for  surgical  purposes  any  subdivision  of  this  space 
is  unnecessary  and  confusing. 

Section  I.  Beginning  with  a  cross-section  which 
lies  just  distal  to  the  web  of  the  fingers,  we  note  the 
following  facts:  The  index  finger  is  slightly  different 

Fig. 19 


Cross-section  No.  I. — See  Fig.  23  for  common  lettering:  SCS,  subcutaneous 
space;  PP,  proximal  phalanx;  DV  and  N,  digital  vessels  and  nerves. 

from  the  middle  and  ring  fingers  in  that  the  space 
which  is  most  superficial,  and  which  we  will  call  "the 
subcutaneous  space,"  does  not  extend  around  the  entire 
finger,  as  do  the  others,  but  at  the  radial  side  the  peri- 
fascial  space  tissue  is  so  dense  as  to  obliterate  it.  It 
will  be  noted  that  this  space  is  deep,  and  that  between 
it  and  the  skin  is  to  be  found  considerable  tissue  which 
is  rather  dense  and  does  not  lend  itself  readily  to  the 
spread  of  pus,  which  in  this  area  is  more  likely  to  come 
to  the  surface  or  infect  the  space  above  mentioned, 
where  it  will  have  little  difficulty  in  spreading  proxi- 
mally  or  distally  (Fig.  19). 


./  STUDY  OF  SERf.ll.  CROSS  SECTIONS  85 

The  litllc  riiii;('r  corrcspoiids  with  llic  index  linger 
in  that  the  space  is  obliterated  ujK^n  its  ulnar  side. 
Ik'tween  the  tendon  and  the  bone  in  each  of  the  four 
lingers  there  is  a  second  space,  and  to  this  we  will 
give  the  name  of  "dorsal  subaponeurotic  space  of  the 
finger,"  for  upon  each  side  of  the  tendon  a  dense  sheet 
of  tissue  is  given  off,  which  unites  firmly  with  the 
periosteum  at  each  side.  Upon  the  flexor  surface  are 
found  the  flexor  tendons  in  their  synovial  sheaths, 
which  sheaths  are  so  closely  united  to  the  periosteum 
that  no  definite  free  spaces  can  be  found. 

The  importance  of  the  close  attachment  of  the  tendon 
sheath  to  the  bone  will  be  brought  out  when  discussing 
tendon-sheath  infection  in  relation  to  the  frequency 
of  osteomyelitis  secondary  to  this  trouble. 

In  my  experience  the  "subcutaneous  space'"  men- 
tioned above  is  frequently  the  seat  of  an  abscess,  and 
care  should  be  taken  not  to  mistake  it  for  a  tendon- 
sheath  infection. 

The  spaces  above  mentioned  all  pass  through  this 
serial  section  into  the  next,  the  second  cross-cut  being 
made  through  the  epiphysis  of  the  proximal  phalanx. 

Section  II,  In  this  section  the  salient  points  may 
be  pointed  out  briefly,  so  that .  we  can  retain  a  com- 
posite picture  w4th  that  which  has  just  been  described 
(Fig.  20). 

The  subcutaneous  space  is  continuous  with  that  in 
Section  I ;  at  the  volar  side,  however,  we  note  a  begin- 
ning division  into  two — a  palmar  and  dorsal. 

The  subaponeurotic  space  is  also  continuous,  and 
the  interossei  muscles  (IM)  begin  to  appear — one 
part  attached  to  the  periosteum  and  one  part  to  the 
dorsal  aponeurotic  sheet.  More  important  still,  we 
see  the  beginning  of  the  lumbrical  muscles  (LAI), 
and  note  particularly  the  relation  of  this  muscle  to 
the  subcutaneous  space,  especially  in  the  third  finger. 


86 


METHODS  OF  STUDY  IN  GENERAL 


The  flexor  tendons  are  still  covered  by  their  synovial 
sheaths. 

Ask  yourself  where  pus  would  land  if  it  followed 
down  along  the  lumbrical  muscle  from  the  palm.  As 
we  follow  these  spaces  into  the  next  section,  we  will 
see  that  the  subcutaneous  spaces  upon  the  abutting 
sides  of  the  fingers  merge  into  each  other;  that  is  to 
say,  the  subcutaneous  spaces  of  the  ulnar  side  of  the 
index  finger  and  the  radial  side  of  the  middle  finger 
join  at  the  web,  being  in  close  relation  to  the  lumbrical 

Fig.  20 


Cross-section  No.  II. — Through  epiphysis  of  proximal  phalanx.  See 
Fig.  23  for  common  lettering:  EPP,  epiphysis  proximal  phalanx;  DV  and  iV, 
digital  vessels  and  nerves. 

muscles;  slightly  proximal  to  this,  as  will  be  seen  in 
the  next  serial  section,  the  space  is  obliterated  between 
the  fingers,  and  only  a  small  part  remains  upon  the 
dorsum  of  each  finger.  It  is  in  connection  with  the 
space  about  the  lumbrical  muscle  in  the  palm,  however, 
so  that  pus  may  spread  from  the  palm  downward  into 
this  space  and  thus  point  on  the  dorsum.  (For  sche- 
matic drawing  showing  this,  see  p.  427.)  The  dorsal 
subaponeurotic  space  is  obliterated  in  this  section, 
i.  e.,  at  the  joint. 


./  STCnr  OF  SF.RI.U.  CROSS  SECriOXS 


S7 


Si-ctioii  III.  The  distal  surface  of  the  lliii'd  serial 
section  is  seen  upon  a  cut  0.5  cm.  |)r()\inial  lotliejoiul 
(Fip:.  21).     Note  here: 

The  absence  of  the  subaponeurotic  si)ace,  except  for 
small  (lix'erticula  hini;  between  the  two  parts  of  the 
interossei  muscle. 

The  absence  of  the  subcutaneous  space  between  the 
fingers.  It  is  continued,  however,  in  the  dorsal  sub- 
cutaneous space  {DSCS)  and  the  space  ab(nit  the 
lumbrical  muscle  (LM). 

Fig.  21 


av  •-iN  LM 


Cross-section  No.  III. — Proximal  to  metacarpophalangeal  joint.  See  Fig. 
23  for  common  lettering:  SB,  sesamoid  bone;  DT,  dense  fibrous  tissue; 
D  V  and  N,  digital  vessels  and  nerves. 

That  the  lumbrical  muscle  lies  in  a  sheath  oi  its 
own,  as  it  were.  This  communicates  with  the  subcu- 
taneous space  of  the  fingers,  and  should  be  followed 
carefully  into  the  palm. 

The  dense  layer  of  tissue  that  crosses  the  whole 
section  lying  around  and  over  the  tendon  sheaths  and 
under  the  lumbrical  muscle. 

That  the  flexor  tendons  are  surrounded  b>-  their 
sheaths. 


88  METHODS  OF  STUDY  IN  GENERAL 

The  spaces  are  all  obliterated  in  passing  either 
through  this  section  or  the  previous  one,  except  the 
synovial  space  about  the  flexor  tendons,  that  about 
the  lumbrical  muscles,  and  the  slight  channel  on  the 
dorsum,  above  noted,  passing  between  the  subcu- 
taneous tissue  of  the  finger  and  the  hand. 

The  surgical  application  of  this  will  be  brought  out 
later. 

Section  IV.  The  fourth  cross-section  lies  two  centi- 
meters above  the  joint  (Fig.  22). 

Fig.  22 


Cross-section  No.  IV. — Two  cm.  proximal  to  joint.  See  Fig.  23  for  com- 
mon lettering:  MFC,  middle  flexion  crease;  PFand  N,  digital  vessels  and 
nerves;  RI,  radialis  indicis. 

The  dorsal  subaponeurotic  spaces,  which  were  ob- 
literated at  the  joint,  are  beginning  again  between  each 
tendon  and  the  corresponding  bone. 

The  dorsal  subcutaneous  spaces  approximate  each 
other. 

The  palmar  tissue  is  still  dense,  with  no  free  passages 
except  those  about  the  lumbrical  muscles  and  those 
along  the  sheaths  of  the  tendons  which  are  still  present, 


./  srinr  of  sf.ri.il  cross  sect ioi\s 


so 


hut    hcL^iu   to  l)c  ohiilcralcd   a^  llic\    i)ass  lIirotiL^h   this 
st'i'ial  sc'tlion. 

As  >•(•(  no  space  has  aijpcarrd  into  which  pus  wcnild 
extend  il  it  were  to  pass  proximall_\   alonj^  these  syno- 

FiG.  23 


DSA5         ECT 


Cross-section  No.  V. — 3-2-  cm.  proximal  to  joint.  Lettering  common  to 
all  plates:  SS,  synovial  sheath;  DSCS,  dorsal  subcutaneous  space;  DSAS, 
dorsal  subaponeurotic  space;  ECT,  extensor  communis  tendon;  FT,  flexor 
tendon;  LM,  lumbrical  muscle;  IM,  interossei  muscles;  M,  metacarpal  bone; 
BV,  bloodvessels;  N,  nerves;  TS,  thenar  space;  MPS,  middle  palmar 
space;  ATP,  adductor  transversus  pollicis;  DIM,  dorsal  interosseous  mem- 
brane; PIM,  palmar  interosseous  membrane;  UB,  ulnar  bursa;  75,  space 
between  adductor  transversus  and  first  dorsal  interosseous;  DIM,  dorsal 
interosseous  membrane;  FLP,  flexor  longus  pollicis  in  its  synovial  sheath; 
HM,  hypothenar  muscles  with  intermuscular  spaces;  IV,  interosseous  vessels 
and  nerve. 

vial  sheaths.  Wc  note,  however,  that  a  small  space 
has  appeared  just  above  the  small  piece  of  abductor 
transversus  muscle,  which  will  become  the  thenar 
space  {TS). 


90  METHODS  OF  STUDY  IN  GENERAL 

Now  let  us  imagine  ourselves  following  through  this 
serial  section  into  the  next.  The  free,  open  spaces 
of  the  hand  appear  suddenly,  the  synovial  sheaths  of 
the  tendons  become  obliterated  after  entering  them, 
the  lumbrical  muscles  join  the  tendons,  and  the  adduc- 
tor transversus,  which  is  the  keynote  to  the  thenar 
space,  begins  to  assume  its  characteristic  relations. 

Section  V.  If  we  cut  across  about  three  centimeters 
above  the  joint,  we  find  the  following,  which  is  well 
represented  in  the  cut  (Fig.  23). 

The  Middle  Palmar  Space 

There  is  a  large,  free  space  with  few  fibrous  septa 
extending  from  the  middle  metacarpal  bone  to  the 
radial  side  of  the  metacarpal  bone  of  the  little  finger. 
It  is  bounded  dorsally  by  a  thin  fibrous  sheet  which 
overlies  the  anterior  interosseous  membrane  and  the 
interossei  muscles;  upon  its  palmar  side  is  a  second 
thin  sheet  separating  it  from  the  tendons  and  the  lum- 
brical muscles  of  the  little  and  ring  fingers.  The  space 
is  limited  upon  its  ulnar  side  by  dense,  fibrous  tissue," 
and  upon  its  radial  side  by  a  dense,  fibrous  sheet 
which  lies  over  the  adductor  transversus.  This  space 
is  probably  the  most  important  in  the  hand,  and  to 
it  is  given  the  name  of  "Middle  Palmar  Space." 

If  we  were  to  note  the  layers  of  tissue  through  the 
middle  of  the  hand,  going  from  the  palm  to  the  dorsum, 
they  would  be  as  follows: 

1.  Epidermis. 

2.  Derma. 

3.  Firmly  meshed  subdermal  connective  tissue. 

4.  Palmar  aponeurosis. 

5.  Loose  mesh  of  connective  tissue,  in  which  lie 
(a)  vessels;  (b)  tendons  with  lumbrical  muscles,  or 
endings  of  the  synovial  sheaths. 


77//;   TIIF.X.IK  SP.ICK  01 

0.    Anlcrioi'  middle  |);iliii;ir  sheet, 
7.    Middle   /'ii/indi'  Space. 
<S.   Posterior  middle  palmar  sheet. 
9.   Vessels. 

10.  Palmar  inlerosseous  membrane,  exlendint;  fnjm 
bone  to  bone. 

11.  Interossei  muscles. 

12.  Posterior  interosseous  membrane. 

13.  Dorsal  subai)oneurotic  space  filled  with  thin 
meshed  connective  tissue  and  vessels. 

14.  Dorsal  aponeurosis  and  tendons. 

15.  Dorsal  subcutaneous  space,  with  loose  connec- 
tive tissue. 

16.  Derma. 

17.  Epidermis. 

The  Thenar  Space 

Upon  the  radial  side  we  note  the  large  mass  of  the 
adductor  transversus,  and  uj^on  its  palmar  side  is 
shown  a  large  space  extending  from  the  metacarpal 
bone  of  the  middle  finger  over  the  muscle  to  the  radial 
side  of  the  hand,  stopping,  however,  at  the  middle 
of  the  radial  side,  at  about  the  level  of  the  palmar 
surface  of  the  bones;  or,  in  other  words,  being  L-shaped 
in  cross-section.  It  will  be  seen  later  that  this  limita- 
tion is  of  importance,  since  it  prevents  injection  masses 
from  passing  freely  to  the  dorsum  of  the  hand,  or 
vice  versa.  This  space  is  known  as  the  "Thenar  Space." 
Upon  its  palmar  side  there  is  a  strong  layer  of  tissue, 
blending  into  the  dense  tissue  of  the  palm,  and  between 
this  dense  palmar  tissue  and  the  space  lie  the  tendon 
and  lumbrical  muscle  of  the  index  finger.  Over  the 
adductor  muscle  is  a  thin  layer  of  tissue  or  perimuscular 
sheath. 

The  middle  palmar  and  thenar  spaces  are  the  two 
most  important  spaces  in  the  hand,  and  it  is  well  to 


92  METHODS  OF  STUDY  IN  GENERAL 

note  their  relations  to  each  other  and  to  adjacent 
structures.  They  will  be  taken  up  later,  and  a  com- 
posite picture  made  from  the  fragmentary  description 
noted  here  and  in  the  following  serial  sections. 

Upon  the  dorsum  the  dorsal  subcutaneous  and  sub- 
aponeurotic spaces  are  well  shown. 

Fig.  24 


EOT 


/  ti^ 


MP5       TMF 


U'         N  LM  ^^^  / 


^^  'X 


ATP     TS     ^,,    m^'M-      1T5 


Cross-section  No.  VI. — Through  distal  part  of  thenar  area.  See  Fig.  23 
for  common  lettering:  ITS,  indefinite  thenar  spaces;  TMF,  tendon  of 
middle  finger;  TM,  thenar  muscles;  PF,  palmar  fascia;  RA,  radial  artery; 
DP  A,  deep  palmar  arch — digital  branches  beginning;  DIA,  dorsalis  indicis 
artery. 

The  synovial  sheaths  have  entirely  disappeared 
except  for  a  small  prolongation  along  the  little  finger 
tendon  ( UB)  and  that  about  the  flexor  longus  pollicle 
(FLP).  The  tendon  sheaths  of  the  three  tendons 
were  obliterated  while  passing  through  this  section. 
The  ulnar  bursa  (UB),  however,  is  seen  to  lie  in 
juxtaposition  to  the  middle  palmar  space  as  do  the 
tendon  sheaths  of  the  middle  and  ring  finger  distal 
to  this  section.  The  tendon  sheath  of  the  index  finger 
is   in    close   connection  with  the   thenar  space    (TS). 


THE   TIIEX.IR  SPACE  93 

Section  VI  (Mr.  24).  This  serial  scctitjn  is  laken 
through  the  distal  part  of  the  thenar  eminence,  and 
thus  shows  the  metacarpal  bone  of  the  thumb  in  cross- 
section.  Here  we  note  the  great  relative  size  of  the 
thenar  space  {TS),  and  yet  it  is  all  upon  the  radial 
side  of  the  middle  metacarpal.  The  lumbrical  muscle 
and  index  tendon  are  separated  from  it  by  a  much 
thinner  septum  than  in  the  previous  section.  The 
tendon  of  the  flexor  longus  pollicis  appears  here 
surrounded  by  its  s^niovial  sheath. 

The  middle  palmar  space  is  much  smaller  and  still 
lies  under  the  group  of  tendons  of  the  middle,  ring, 
and  little  fingers.  Upon  the  ulnar  side  of  this  group 
we  see  the  ulnar  synovial  bursa  in  juxtaposition  to  the 
space,  yet  the  septum  between  them  must  be  strong, 
since  the  injection  masses  in  this  bursa,  noted  later, 
have  a  greater  tendency  to  rupture  into  the  forearm 
than  into  this  space. 

Upon  the  dorsum  we  still  find  our  subaponeurotic 
and  subcutaneous  spaces,  while  over  the  thenar  area 
the  subcutaneous  tissue  is  also  lax,  and  either  of  the 
two  former  spaces  can  be  made  to  communicate  with  it. 

The  deep  palmar  arch  {DP A)  appears  in  this 
section,  and  its  relation  to  the  middle  pahiiar  space  and 
the  synovial  sheath  should  be  noted.  We  see  that  there 
is  not  much  danger  of  injuring  it  if  care  is  taken  in 
operating. 

In  the  cavses  examined  the  flexor  longus  pollicis 
with  its  tendon  sheath  is  separated  from  the  thenar 
space  by  a  considerable  amount  of  tissue,  and  while 
rupture  from  it  into  the  space  is  possible  (particularly 
in  those  cases  accompanied  by  inflammatory  destruc- 
tion), yet  it  would  be  more  likely  to  rupture  at  the 
upper  end  of  the  synovial  sac  into  the  cellular  tissue 
of  the  forearm.  Experimental  evidence  to  support 
this  will  be  brought  forward  later  (see  pj).  125  and  126). 


94 


METHODS  OF  STUDY  IN  GENERAL 


Section  VII  (Fig.  25).  In  the  seventh  section, 
taken  through  the  base  of  the  palm,  the  middle  palmar 
space  and  the  thenar  space  are  seen  to  have  shrunk 
into  insignificance.  They  lie  close  together  under  the 
group  of  tendons,  the  middle  palmar  space  being  more 
superficial.  They  are  still  separated  by  a  thin  sheet, 
however,  in  those  specimens  examined. 

Pig.  25 


Cress-section  No.  VII. — See  Fig.  23  for  common  lettering:  RV  and  N, 
radial  vessels  and  nerve;  MN  and  V,  median  nerve  and  vessels;  UV  and 
N,  ulnar  vessels  and  nerve. 


One  or  two  indefinite  spaces  are  present  about  the 
thenar  region.  They  are  of  little  importance,  however, 
except  to  note  that  they  are  present  between  the 
groups  of  muscles,  and  localized  infection  can  occur 
in  them  under  exceptional  circumstances. 


THE  IIYPOTIIENAR  SPACE 


95 


The  dorsal  spaces  remain  the  same,  except  that  the 
subaponeurotic  is  more  constricted. 

The  tendon  sheaths  are  seen  in  four  places— the  ulnar 
bursa  (UB),  the  sheath  about  the  flexor  longus 
pollicis  (FLP),  and  the  two  intermediate  sheaths 
about  the  superficial  tendons  in  juxtaposition  to  the 
ulnar  bursa.  These  will  be  discussed  later  (see  pp. 
107  and  109). 


The  Hypothenar  Space 


Nothing  as  yet  has  been  said  of  the  hypothenar  area, 
since  it  was  desirable  to  avoid  confusion.     However, 


Fig.  26 


ecu 


UV-N.N 


Cross-section  No.  VIII. — See  Fig.  23  for  common  lettering:  i^Fand  N, 
radial  vessels  and  nerves;  MN  and  V,  median  nerve  and  vessels;  UV  and 
N,  ulnar  vessels  and  nerves;  PMP5,^prolongation  of  middle|_^pa!mar  space.  ,  ; 

a  glance  at  this  section,  and  at  those  which  have  pre- 
ceded, shows  very  clearly  that  while  it  is  possible  for 


96  METHODS  OF  STUDY  IN  GENERAL 

pus  to  accumulate  in  the  intermuscular  septa  of  this 
space,  yet  it  would  be  absolutely  localized  here,  and 
would  spread  to  the  surface.  It  would  not  enter 
either  the  middle  palmar  space  or  the  ulnar  synovial 
bursa.  Such  infections  would  be  of  little  surgical 
interest,  owing  to  their  localized  nature. 

Section  VIII  (Fig.  26).  In  the  eighth  section, 
taken  at  the  wrist,  the  middle  palmar  and  thenar 
spaces  can  still  be  found,  but  they  are  so  small  as  to  be 
of  little  practical  importance,  since  any  inflammation 
in  them  would  probably  be  followed  by  closure.  Their 
behavior  under  forcible  injection  will  be  noted  later. 

While  it  might  be  possible  by  forcible  dissection  to 
produce  a  dorsal  subaponeurotic  space,  yet  it  should 
not  be  described  as  being  present. 

The  dorsal  subcutaneous  space  can  be  demonstrated, 
but  it  is  more  difficult  to  do  so  here  than  in  the  previous 
sections,  since  more  of  the  fibers  tend  to  intermingle 
from  layer  to  layer. 

The  synovial  sheaths  about  the  dorsal  tendons  also 
appear  in  this  section. 


Discussion  of  the  Relations  of  the  Middle  Palmar  and 
Thenar  Spaces 

The  inter-relation  of  the  middle  palmar  and  thenar 
spaces  is  of  very  great  interest  to  the  surgeon,  and  to 
understand  it  the  roof  and  floor  of  the  two  spaces  must 
be  discussed  together.  They  are  separated  from  each 
other  at  the  middle  metacarpal  bone  by  firm  septa, 
so  that  neither  one  communicates  with  the  other,  nor 
does  either  overlap  to  the  other  side  of  this  bone.  The 
tendons  of  the  third  and  fourth  fingers,  with  their 
lumbrical  muscles,  lie  just  above  the  middle  palmar 
space,  separated  from  it  by  only  a  thin,  indefinite 
membrane,  while  upon  the  palmar  side  of  this  group 


'/•///■;  Ml /)/)/./:  r. 11. MIR   im)  tiii.wir  si'.ices       wi 

arc  a  lew  iiKlctiiiiU'  si)ac"C's;  l)iit  i)iis  niiisl  pass  around 
tlu'  tciulons  lo  llu'ir  dorsal  siirfacx-  and  rui)turL'  into 
(lie  middle  palmar  spar(\  since  in  every  other  direction 
linn  tissue  is  toiiiid.  Such  a  course  mii^ht  be  followed 
in  an  infection  passing;  upward  along  the  lumbrical 
muscles.  If  it  follows  along  the  syncnial  sheath  of  the 
ring  hnger.  and  hnall>'  ruptures  from  the  proximal 
hliiid  end,  it  will  pass  ultimateh'  into  this  space.  The 
same  holds  true  for  the  tendcjn  sheath  of  the  little 
linger  in  those  cases  in  which  it  is  separated  from 
the  ulnar  bursa.  To  the  ulnar  side  of  the  tendon  of 
the  little  finger  is  seen  the  small  synovial  space  repre- 
senting the  c(jntinuation  of  the  synovial  sheath  of  the 
little  finger  into  the  synovial  sheath  of  the  tendons 
above,  known  as  the  ulnar  bursa. 

It  will  be  seen  that  the  lumbrical  muscle  and  tendon 
of  the  index  linger  occupy  the  same  relative  position 
to  the  thenar  space  that  the  third  and  fourth  do  to 
the  middle  palmar  space,  with  this  exception,  that  in 
those  hands  which  have  been  examined  the  sheet  of 
tissue  separating  it  from  the  thenar  space  is  somewhat 
firmer;  still,  it  is  not  so  dense  as  that  upon  the  other 
three  sides,  and  here  also,  then,  it  must  communicate 
with  the  space  below  it. 

The  lumbrical  muscle  and  tendon  of  the  middle 
finger  in  Section  \T  occupy  an  intermediary  place 
between  the  two  spaces,  but  in  the  previous  section 
they  will  be  seen  to  lie  over  the  middle  palmar  space, 
at  which  site  the  enveloping  fascia  is  much  thinner, 
so  that  we  w^ould  have  reason  to  believe,  from  an 
anatomical  standpoint,  that  pus  spreading  along  this 
tendon  would  communicate  more  easily  with  the  middle 
palmar  space,  and  experimental  injections  of  the 
synovial  sheath  substantiate  this  reasoning. 

We  have  now  discussed  all  of  the  relations  of  these 
spaces   except    the    lloor,    or    dorsal   surface,    and    the 

7 


98  METHODS  OF  STUDY  IN  GENERAL 

proximal  prolongation.  The  latter  we  will  speak  of 
in  the  chapter  dealing  with  anatomy  of  the  forearm. 
Concerning  the  floor,  however,  it  is  well  to  mention 
several  things.  Owing  to  the  closed  nature  of  these 
pockets,  it  is  customary  for  clinicians  to  draw  attention 
to  the  frequency  of  rupture  from  them,  through  be- 
tween the  bones,  to  the  dorsal  surface. 

In  the  middle  palmar  space  the  floor  is  composed 
of  a  very  thin  fascial  layer,  through  which  pus  could 
rupture  easily,  were  it  not  for  the  support  given  it 
by  the  interossei  muscles  and  the  interosseous  mem- 
brane, upon  which  it  lies.  Should  inflammatory 
destruction  of  this  sheet  arise,  however,  or  rupture 
ensue,  the  interossei  muscles  would  still  offer  a  slight 
resistance,  for  there  is  no  distinct  channel  leading  to 
the  dorsum,  although  the  intermuscular  septa  do  tend 
in  that  direction.  Having  come  through  these,  how- 
ever, the  pus  would  then  meet  the  septum  passing 
from  one  bone  to  the  other  upon  the  dorsal  surface  of 
the  interossei  muscles.  If  the  pus  meets  and  over- 
comes the  various  obstructions,  which  it  might  do 
in  chronic  and  exceptional  cases,  it  would  then  lie 
beneath  the  tendons  upon  the  dorsal  surface,  or  in  the 
dorsal  subaponeurotic  space. 

Now  let  us  go  back  to  the  thenar  space  and  its  floor, 
or  dorsal  wall.  This  is  slightly  more  complex,  in  that 
the  muscular  masses  making  up  the  floor  confuse  us. 
For  the  most  part  it  is  made  up  of  the  adductor 
transversus  and  the  adductor  obliquus,  and  in  those 
cases  where  there  is  little  tension  upon  the  contents  it 
would  be  limited  dorsally  by  them  and  the  thin  sheet 
of  fascia  over  the  muscles.  Upon  the  other  hand,  if 
the  tension  were  increased,  it  would  be  very  easy  for 
the  contents  of  the  cavity  to  pass  between  these 
muscles  and  come  to  lie  upon  the  dorsal  surface  of  the 
adductor  transversus.     That  is  to  say,  it  would  come 


REC.IPITULATiON  99 

against  the  firsl  dorsal  intcnjsst'ous  upon  the  dorsum 
of  llu'  I  lunar  region  about  on  a  Icxcl  with  the  meta- 
('ar|)()|)lialangc'al  joint  of  the  lliiinih,  and  thus,  if  there 
were  an\  inllamniatory  aetion  present,  spread  to  the 
cutaneous  tissue  at  the  web;  or,  if  the  dorsal  inter- 
osseous muscle  were  unimjxjrtant,  in  the  dorsal  sub- 
cutaneous tissue  of  the  thenar  region.  I^^xi)eri mental 
evidence  will  be  adduced  later  to  prove  this  can  occur. 

Recapitulation 

W'c  note  that  we  have  six  important  fascial  spaces 
with  their  tributaries  in  which  pus  can  accumulate. 

1.  The  dorsal  subcutaneous,  which  is  an  extensive 
area  of  loose  tissue,  wathout  definite  boundaries, 
allowing  pus  to  spread  over  the  entire  dorsum  of  the 
hand. 

2.  The  dorsal  subaponeurotic,  limited  upon  its  sub- 
cutaneous side  by  the  dense  tendinous  aponeurosis 
of  the  extensor  tendons,  upon  the  deep  side  by  the 
metacarpal  bones,  having  the  shape  of  a  truncated 
cone,  with  the  smaller  end  at  the  wrist  and  the  broader 
at  the  knuckle.  Laterally  the  aponeurotic  sheet  shades 
ofT  into  the  subcutaneous  tissue. 

3.  The  hypothenar  area,  a  distinctly  localized  space. 

4.  The  thenar  space,  occupying,  approximately,  the 
area  of  the  thenar  eminence.  Superficially  its  internal 
boundary  is  indicated  by  the  adduction  crease  of  the 
thumb.  It  lies  entirely  upon  the  radial  side  of  the 
middle  metacarpal.  It  should  be  remembered  that 
this  space  lies  deep  in  the  palm,  just  above  the  adductor 
transversus. 

5.  The  middle  palmar  space,  with  its  three  diver- 
ticula below  along  the  lumbrical  muscles,  limited  by 
the  middle  metacarpal  bone  upon  the  radial  side, 
overlapped  by  the  ulnar  bursa  upon  the  ulnar  side,  and 


100  METHODS  OF  STUDY  IN  GENERAL 

separated  from  the  thenar  space  by  a  partition  which 
is  very  firm  everywhere  except  at  the  proximal  end, 
where  it  is  rather  thin.  A  small  isthmus  can  be  found 
leading  from  the  proximal  end  of  the  space  under  the 
tendons  and  ulnar  bursa  at  the  wrist  into  the  forearm. 
6.  The  web  space,  an  area  of  loose  connective  tissue 
between  the  bases  of  the  fingers,  with  prolongations 
distally  into  the  subcutaneous  tissue  at  the  sides  of  the 
fingers,  and  proximally  into  the  subcutaneous  tissue 
of  the  dorsum  on  the  dorsal  surface  and  into  the 
connective-tissue  spaces  around  the  lumbrical  muscle 
on  the  palmar  surface.  The  corroboration  of  our  state- 
ment as  to  the  outlines  of  these  spaces  will  be  brought 
out  in  the  chapter  upon  experimental  injections 
(Chapter  IX). 


CHAPTER    \  I  I  I 

THE    TENDON    SHEATHS:      A    DISCUSSION    OF    THEIR 

ANATOMICAL  DISTRIBUTION  AND  RELATIONS, 

WITH  SURGICAL  DEDUCTIONS 

From  a  consideration  ui  the  cross-sections  we  have 
described  in  the  previous  chapters  it  is  possible  to 
give  a  composite  picture  of  the  various  tendon  sheaths 
from  an  anatomical  and  surgical  standpoint.  In  the 
following  description  the  well-known  anatomical  points 
which  have  no  bearing  on  the  subject  in  hand  will 
not  be  dealt  with.  It  is  my  intention  to  emphasize 
those  facts  which  will  aid  us  in  understanding  the  course 
an  infection  will  pursue,  and  will  point  to  the  proper 
course  of  treatment.  Therefore,  before  reading  this 
one  should  have  a  clear  conception  of  the  anatomy  of 
the  six  fascial  spaces  described  in  the  pre\ious  chapter. 

The  particular  relation  of  the  sheaths  to  the  six 
fascial  spaces  will  be  emphasized  in  the  chapter  deal- 
ing with  experimental  injections  (Chapter  IX).  These 
will  also  serve  to  corroborate  the  anatomical  state- 
ments made  here. 

SHEATHS  UPON  THE  FLEXOR  SURFACE 

From  a  surgical  standpoint,  the  sheaths  upon  ihe 
flexor  surface  are  the  most  important.  The  anatomy 
of  these  may  be  discussed  under  four  heads:  (i)  The 
tendon  sheaths  for  the  index,  middle,  and  ring  fingers; 
(2)  the  tendon  sheath  for  the  thumb  with  its  prolonga- 
tion in  the  hand  (radial  bursa);  (3)  the  tendon  sheath 
of  the  little  finger  and  its  prolongation  in  the  jxilm 
(ulnar  bursa);  (4)  the  communications  between  these 
various  sheaths. 


102  THE  TENDON  SHEATHS 


The  Sheaths  of  the  Index,  Middle,  and  Ring  Fingers 

These  begin  just  distal  to  the  distal  interphalangeal 
joint  and  extend  into  the  palm,  approximately  a 
thumb's  breadth  proximal  to  the  web;  or  the  point  of 
extension  can  be  designated  by  drawing  a  line  between 
the  end  of  the  proximal  palmar  crease  at  the  base  of 
the  index  finger  and  the  end  of  the  distal  palmar  crease 
at  the  base  of  the  little  finger.  This  line  represents  the 
approximate  extension  of  these  sheaths  into  the  palm. 
It  will  be  seen  by  noting  Fig.  22  that  at  the  distal 
portion  of  the  palm  there  is  a  sheet  of  dense  tissue 
enclosing  the  tendon  sheaths  and  lumbrical  muscles. 
The  sheaths  extend  one-fourth  inch  proximal  to  this 
into  the  loose  palmar  tissue.  This  fact  is  of  consider- 
able importance  from  a  surgical  standpoint  (see  pp. 
117  and  168). 

While  passing  through  the  dense  tissue  mentioned 
above,  these  sheaths  have  on  either  side  the  space 
called  the  lumbrical  canal,  through  which  pass  the 
lumbrical  muscles  and  digital  branches  of  the  arteries 
and  nerves  (Fig.  21).  This  is  also  of  surgical  impor- 
tance (see  pp.  177  and  208). 

As  we  pass  distally,  we  find  considerable  tissue 
between  the  metacarpophalangeal  joint  and  the  sheath 
proper,  while  more  distally,  as  we  come  to  the  base 
of  the  proximal  phalanx,  we  note  that  the  sheath 
approaches  the  bone  and  is  in  close  relation  with  the 
loose  connective  tissue  going  entirely  around  the  bone. 
The  surgical  importance  of  this  will  be  brought  out 
later. 

At  the  proximal  interphalangeal  joint  (Fig.  119)  we 
find  considerable  tissue  between  the  sheath  and  the 
joint,  while  over  the  base  of  the  middle  phalanx,  f.  e., 
at  the  epiphyseal  line  (Fig.  27),  there  is  little  or  no 


KUK.irii^  or  IX DEW  Minni.K,  ./\n  rixc  f/xcf.rs    ]{):] 

tissue  Ix'lwccn  the  slicalh  and  the  \u)\]l\  F'rom  this 
point  distally  the  relation  to  the  bone  is  not  so  inti- 
mate. At  the  distal  end  the  relation  of  the  structures 
can  be  seen  by  studying  Fig.  2.  (For  surgical  appli- 
cation, st'c  p.  164  and  Chapter  XXVI 1 1.) 

These  sheaths  bear  almost  the  same  relation  to  the 
respective  fingers.  They  do  differ  slightly  in  their 
rc-lalion  to  the  palm  of  the  hand  as  I  pointed  out  in 
Chapter  VII.    The  proximal  end  of  the  sheath  for  the 

Fig.  27 


Cross-section  through  the  epiphysis  of  the  middle  phalanx.  Notice  the 
loose  mesh  and  the  small  amount  of  connective  tissue  between  the  tendon 
and  the  bone. 

index  finger  is  in  relation  to  the  thenar  space,  while 
that  of  the  middle  finger  is  most  often  in  relation  to 
the  middle  palmar  space,  although  at  times  it  will 
allow  of  rupture  into  the  thenar  space,  possibly  through 
rupture  into  the  lumbrical  space  between  the  index 
and  middle  finger  and  thence  into  the  thenar  space. 
However,  this  lumbrical  space  itself  most  often  leads 
into  the  middle  palmar  space.  The  tendon  sheaths  of 
the  ring  finger  and  of  the  little  finger  are  in  relation  to 
the  middle  palmar  space. 


104  THE  TENDON  SHEATHS 

The  Radial  Bursa  and  the  Tendon   Sheath  of  the  Flexor 
longus  pollicis 

This  is  of  great  importance  from  a  surgical  stand- 
point, owing  to  the  fact  that  in  youth  and  adult  life 
the  sheath  nearly  always  communicates  with  the 
enlarged  sac  of  the  tendon  sheath  at  the  wrist  (19  in 
20  cases,  Poirier).  The  entire  sheath  has  been  given 
the  name  of  radial  bursa,  although  technically  speak- 
ing it  should  be  applied  to  only  the  proximal  part  at 
the  wrist. 

The  sheath  begins  distally  at  the  base  of  the  distal 
phalanx  and  extends  proximally  a  thumb's  breadth 
proximal  to  the  anterior  annular  ligament.  It  lies 
first  in  close  proximity  to  the  proximal  phalanx,  but 
at  the  distal  end  of  the  metacarpal  bone  becomes 
separated  from  the  bone  by  the  muscles  of  the  thumb 
lying  between  the  outer  head  of  the  flexor  brevis 
pollicis  and  the  adductor  obliquus  pollicis  (Figs.  24 
and  25).  At  times  (i  to  20,  Poirier)  there  is  a  separa- 
tion of  the  sheath  into  two  parts  at  about  the  middle 
of  the  metacarpal  bone.  This  is  frequently  only  a 
thin  diaphragm.  The  sheath  is  generally  well  sepa- 
rated by  connective  tissue  from  the  metacarpo- 
phalangeal joint  and  an  infection  may  spread  from 
the  joint  to  the  sheath,  or  vice  versa,  but  either  is 
uncommon.  It  lies  superficial  to  the  proximal  end  of 
the  thenar  space,  in  juxtaposition  to  the  flexor  tendons 
in  the  carpal  canal  (Fig.  24)  and  passes  upward  to 
terminate  about  an  inch  above  the  annular  ligament 
by  a  rounded  cul-de-sac  extending  under  the  deep 
surface  of  the  tendon,  corresponding  to  the  radio- 
carpal joint  and  the  lower  end  of  the  radius,  lying 
on  the  pronator  quadratus. 

The  communication  between  this  and  the  ulnar  bursa 
will  be  discussed  later.    The  motor  nerve  to  the  thenar 


nil'  ri.\  IR  nrns.i   ixn  rui:  i.rrri.r.  ii\(:i:r     lor. 

iiiiixlc  \\v>  williiii  .1  liiiiw^cr's  hi'cadtli  disl.il  to  llic 
aniuilar  liu.<im('iil  and  Mipcilicial  lo  (he  ->lica(li  (sec 
p.  109). 

TiiK  Ulnar  Bursa  and  the  Siieatii  of  the  Tendon  of  the 
Little  Finger 

The  tendon  sheath  of  the  flexor  tendon  of  the  little 
finger  comminiicates   freely  with   the   ulnar   bursa   in 

Fig.  28 


X-ray  picture  upon  which  are  shown  two  types  seen  in  the  flexor  tendon 
sheaths.  Note  that  in  the  hand  upon  the  left  side  there  is  a  continuation 
between  the  Httle  finger  and  the  thumb  and  the  ulnar  bursa  and  radial  bursa 
respectively.  Note  also  the  connecting  sheaths  between.  In  the  hand 
upon  the  right  side  the  sheaths  are  separated,  not  alone  fmin  their  respec- 
tive fingers,  but  from  each  other. 


106  THE  TENDON  SHEATHS 

about  one-half  of  the  cases  according  to  Poirier,  but 
statistics  vary  somewhat  on  this  point.  When  the 
separation  is  present  it  is  of  any  grade,  from  a  simple 
narrowing  to  a  complete  occlusion  some  millimeters  in 
length.  In  these  cases  the  sheath  corresponds  in  length 
to  those  of  the  other  fingers.  Also  the  relations  to  the 
joints  and  spaces  are  the  same  except  that  there  is 
no  lumbrical  canal  upon  the  ulnar  side  of  the  proximal 
end.  The  sheath  extends  into  the  middle  palmar 
space,  and  the  lumbrical  canal  upon  its  radial  side 

Fig.  29 


UB  S     S  FLP 

Showing  the  relation  of  the  tendons  and  synovial  sheaths  at  the  wrist. 
Note  in  this  drawing  the  four  pockets  in  the  ulnar  bursa  instead  of  three  as 
commonly  described;  also  the  tendon  sheath  of  the  flexor  longus  poUicis 
and  the  accessory  synovial  sheaths  (SS).  See  text  for  description  of  the 
difference  between  the  relations  of  the  tendons  shown  in  Figs.  25  and  29. 

communicates  with  the  same  area.  In  this  relation 
it  should  be  remembered  that  these  muscles  do  not 
lead  into  the  thenar  and  middle  palmar  spaces  directly, 
but  lie  just  superficial  to  them,  in  a  loft,  as  it  were, 
from  which  pus  easily  extends  into  the  spaces. 

The  ulnar  bursa  proper  (Fig.  28)  begins  at  the  proxi- 
mal end  of  the  finger  sheath,  spreads  out  rapidly,  and 
becomes  a  good-sized  sac  overlapping  the  metacarpal 
of  the  ring  finger  and  the  head  of  the  middle  meta- 
carpal, passes  under  the  anterior  annular  ligament 
and  extends  a  thumb's  breadth  above  this,   lying  in 


TiiF.  cf.x.iR  nrRS.f  ,f\i)  Tin:  i.irri.i:  fisc.er     to? 


relation    to   the   lowci'  end    of   tin-    ulna   aiul    the    iiliiar 
si(k'   of    tlu'   carpus   and    the    radio-ulnar   arliculalion, 


Fig.  30 


lyini;  ui)on  the  pronator  quadratus.  It  docs  not  sur- 
round llu  tendons  as  a 
whole,  but  lies  to  the  ulnar 
side  of  the  g;roup  of  super- 
[\vvd\  and  deep  flexors  and 
onh  envelops  them  as  if 
they  were  pushed  in  alonii, 
the  outside.  It  follows,  then, 
that  the  ulnar  side  of  the 
sac  is  free  while  the  radial 
side  envelops  the  tendons, 
forming  three  spaces  or 
arches,  as  it  were,  the  most 
superficial  between  the  apo- 
neurosis and  the  superficial 
tendons,  the  middle  between 
the  superficial  and  deep 
tendons,  and  the  third  be- 
tween the  deep  tendons 
and  the  carpal  canal  (Figs. 
25,  29,  and  30).  These  all 
open  upon  the  ulnar  side 
into  a  common  space.  This 
arrangement,  first  drawn 
attention  to  by  Leguey,    I 

,     ,.  .       .  ,     ,  Photograph     after     Poirier,     in 

believe,    is    in    general    true,       ^.j^j^j^    ^^e   ulnar  bursa   has    been 

but  the  arrangement  varies      opened,  showing  its  extension  into 
at    different     levels    and     in       ^he    little    finger    and    its  closure 

about     the     tendon    of     the    ring 

different  individuals,  as  can     finger. 

be  seen  by  examining  Fig. 

29,  where  there  are  four   pockets,  and  none  of  them 

very    deep.     Moreover,   the   tendons  upon  the    radial 

side  frequently  have  sheaths  separate  from  the  ulnar 

bursa,  as  will  be  mentioned  under  our  fourth  caption, 


108 


THE  TENDON  SHEATHS 


"The  Intercommunication  of  the  Sheaths."  Attention 
should  also  be  drawn  to  the  fact  that  the  superficial 
palmar  arch  with  some  of  the  unimportant  branches 
of  the  ulnar  nerve  lies  superficial  to  the  sheath. 
More  important,  however,  is  the  fact  that  the  sheath 
overlies  the  middle  palmar  space,  making  part  of  its 
roof,  as  it  were  (Fig.  31). 

Fig.  31 


^^^^0-,-' 

M^     H 

.sIfr^^*■^■^'''  ^  '^ 

MPi>      TMF 

;^       ^  -^        U\ 

N 

HM            PF 

Cross-section  No.  VI. — Through  distal  part  of  thenar  area.  See  Fig.  23 
for  common  lettering:  ITS,  indefinite  thenar  spaces;  TMF,  tendon  of  middle 
finger;  TM,  thenar  muscles;  PF,  palmar  fascia;  RA,  radial  artery;  DP  A, 
deep  palmar  arch — digital  branches  beginning;  DIA,  dorsalis  indicis  artery. 

Above  the  anterior  annular  ligament  it  is  well  ta 
note  that  the  tendons  of  the  palmaris  longus  and  the 
'flexor  carpi  radialis  lie  above  the  radial  bursa,  and 
that  by  drawing  the  tendon  of  the  flexor  carpi  radialis 
to  the  radial  side  one  can  come  down  directly  upon  the 
flexor  longus  pollicis  and  its  sheath.  Attention  should 
likewise  be  drawn  to  the  fact  that  the  median  nerve 
lies  between  the  two  bursae  and  somewhat  deeply. 


Tiir:  ixrEkcoMMiMcirios  oi-  the  siie.itiis    lou 


TlIK     InTKKCOMMINK  Alios    OK    TlIK    SlIKATIlS 

J'oiricM''  (lis(.-ussc's  llu-  roinniunicalioii  helwfi'ii  the 
biirsiu  as  lollows: 

"The  syn()\ial  slicatlis  of  the  |)aliii  liaxc  no  com- 
niiiniralion  willi  cacli  other,  and  the  auth(jrs  cite  in 
pi'oot  ot  this  the  ease  (A  Gosselin,  who  had  observed 
it  only  once.  However,  the  result  of  m>-  observatifjn 
has  been  thai  this  communication  between  the  two 
important  sheaths  is  very  frequent  in  the  adult.  It 
is  found  in  about  half  of  the  cases.  The  connection 
is  made  by  a  median  synovial  sheath  which  I  will 
describe. 

"Accessory  syno\  ial  sacs:  The  writers  call  atten- 
tion to  the  occasional  existence  of  synovial  sheaths  in 
addition  to  the  two  large  synovial  sheaths,  w^hich  they 
call  accessory  sheaths,  and  are  found  at  times  along 
the  flexor  tendons  of  the  index  finger.  They  lie  be- 
tween the  ulnar  and  radial  bursse,  being  found  especially 
along  the  deep  tendon.  My  researches  show  that  these 
synovial  sheaths  are  two  in  number.  They  ought  not 
to  be  called  accessory,  since  one  of  these  is  almost 
always  present.  I  have  named  them  the  intermediary 
anterior  and  posterior  palmar  s^^novial  sheaths. 

"The  intermediary  posterior  palmar  sheath:  This 
should  be  described  as  a  normal  sheath,  since  one  finds 
it  about  eight  times  out  of  ten.  It  lies  between  the 
carpal  canal  and  the  flexor  profundus  of  the  index 
finger,  and  commences  above  the  wrist  at  the  edge  of 
the  radius.  It  spreads  out  at  the  level  of  the  upper 
border  of  the  semilunar  bone  and  goes  down  more 
or  less  on  the  tendon  of  the  flexor  profundus,  varying 
from  3  to  8  cm.  To  see  it,  it  is  necessary  to  cut  trans- 
versely  across   the   mass   of   muscles   and    tendons   in 

^  P.  Poiricr  el  A.  Cliarpy,  TrailO  d'AiuUdiiuc  Huniaiiic,  Tdinc  ii.  S.  i.Sy. 


no  THE  TENDON  SHEATHS 

the  lower  third  of  the  forearm  and  turn  the  distal  end 
down  toward  the  fingers.  It  is  by  the  intervention  of 
this  sheath  that  the  ulnar  and  radial  bursse  communi- 
cate ordinarily. 

"The  anterior  intermediary  palmar  sheath:  This  is 
found  in  hardly  half  of  the  cases.  Much  smaller  than 
the  preceding,  it  is  found  placed  between  the  super- 
ficial and  deep  tendons  of  the  index  finger. 

"Both  of  these  appear  later  than  the  others,  and  it 
is  very  rare  to  find  them  as  completely  organized.  In 
general,  their  walls  lack  the  moist  glassiness  character- 
istic of  complete  development." 

It  is  said^  also  that  the  synovial  sheaths  of  the  ring, 
middle,  and  index  fingers  communicate  exceptionally 
with  the  ulnar  bursa,  following  their  respective  tendons, 
occurring  in  the  order  of  frequency  as  the  fingers  are 
named  above.  Again,  attention  should  be  drawn  to 
the  fact  that  the  intermediary  sheaths  may  differ 
from  that  type  mentioned  by  Poirier.  I  have  dissected 
one  case  in  which  the  profundus  tendons  of  the  index 
and  middle  fingers  had  separate  sheaths.  Communi- 
cating with  the  ulnar  bursa  (Fig.  25)  at  this  level 
the  anterior  intermediary  sheath  was  absent,  but  2  cm. 
higher  up  the  sheath  of  the  middle  finger  profundus  had 
disappeared,  while  the  anterior  and  posterior  interme- 
diary sheaths  were  present  (Fig.  29).  The  communi- 
cation here,  then,  would  have  taken  place  as  follows: 
Ulnar  bursa,  sheath  about  the  middle  finger  profundus, 
sheath  about  the  index  finger  profundus,  or  posterior 
intermediary  sheath,  and,  in  this  case  apparently, 
anterior  intermediary  sheath,  to  the  radial  bursa.  It 
can  be  seen  that  in  a  fulminating  type  of  infection, 
such  as  a  streptococcus  involvement,  the  process  would 
spread  to  the  radial  bursa,  but  in  the  more  chronic 

^  Tilleau,  Traite  d'Anatomie  Topographique. 


Fig.  32 


r«^g^^ 


^■t^yi"':"^-'MiiAK:- 


■>•«:■'» '5^w:^g:ja«Bg'j»j«y? 


M 


An  .v-ray  picture  of  a  cadaver  hand  in  which  the  tentlon  sheaths  have 
been  injected  with  red  lead.  The  outline  of  the  ulnar  bursa  and  radial  bursa 
with  tendon  prolongations  is  clearly  shown.  Note  the  distance  of  the  radial 
bursa  from  the  metacarpal  bone  of  the  thumb  and  the  relation  of  the  ulnar 
bursa  to  the  metacarpal  bone  of  the  middle  finger. 


112 


THE  TENDON  SHEATHS 


types  this  devious  course  offers  many  chances  for 
adhesive  occlusion  of  the  channel  (Fig.  32).  This  will 
be  discussed  later  (see  p.  207). 


Fig.  33 


Photograph  from  Bardeleben,  showing  tendons  upon  the  back  of  the  hand 
passing  under  the  posterior  annular  Hgament. 


THE  SHEATHS  UPON  THE  DORSUM 

The  synovial  sheaths  of  the  hand  upon  the  dorsum 
are  six  in  number.    These  begin  just  above  the  posterior 


THE  SHEATHS  UPON  THE  DORSUM  113 

annular    ligament    and    pass    under    and    through    it 
(Figs.  26  and  33).     They  are  found  as  follows: 

1.  Lying  upon  the  outer  side  of  the  styloid  process 
of  the  radius,  for  the  extensor  ossis  metacarpi  pollicis 
and  the  extensor  brevis  pollicis.  They  may  have 
separate  sheaths  and  are  5  to  6  cm.  in  length. 

2.  Behind  the  styloid  process,  for  the  tendons  of 
the  extensor  carpi  radialis  longior  and  brevior.  These 
are  5  to  6  cm.  in  length  and  communicate  with  the 
sheath  of  the  extensor  longus  pollicis  through  an  oval 
opening  by  way  of  the  longior  (Poirier). 

3.  Overlapping  the  above  tendons,  and  communica- 
ting with  them  as  described,  we  have  the  sheath  of  the 
extensor  longus  pollicis.     This  is  6  to  7  cm.  in  length. 

4.  To  the  ulnar  side  of  this  we  find  the  large  sheath 
enclosing  the  tendons  of  the  extensor  communis  digi- 
torum  and  the  extensor  indicis.  It  is  5  to  6  cm.  in 
length  and  terminates  below  in  three  prolongations.  The 
radial  one  encloses  the  communis  tendon  to  the  index 
finger  and  the  extensor  indicis;  the  middle,  the  com- 
munis tendon  to  the  middle  finger;  the  one  on  the  ulnar 
side  covers  the  tendons  to  the  third  and  fourth  fingers. 

5.  One  opposite  the  interval  between  the  radius  and 
ulna,  for  the  extensor  minimi  digiti.  This  is  longer 
than  the  others,  being  6  to  7  cm.  in  length.  Covering 
the  upper  one-third  of  the  length  of  the  third  interos- 
seous space,  it  may  bifurcate  below,  following  the  two 
branches  of  the  tendon. 

6.  Upon  the  back  of  the  ulna,  the  synovial-  sheath 
of  the  tendon  of  the  extensor  carpi  ulnaris.  This  is 
4  to  5  cm.  in  length. 


CHAPTER    IX 

THE    RELATION    BETWEEN    THE    SYNOVIAL 
SHEATHS  AND  THE  FASCIAL  SPACES 

A  STUDY  BY  EXPERIMENTAL  INJECTION  OF  THE  OUT- 
LINES,   BOUNDARIES,   AND    DIVERTICULA   OF   THE 
FASCIAL  SPACES  AND  THE  RELATION  OF  THESE 
TO  THE  SYNOVIAL  SHEATHS 

In  my  desire  to  corroborate  the  findings  by  dissec- 
tion in  relation  to  the  fascial  spaces  and  tendon  sheaths 
which  have  been  detailed  in  the  two  preceding  chapters, 
a  large  number  of  hands  were  injected  after  the  manner 
described  in  Chapter  VII.  The  results  obtained  were 
most  satisfactory,  since  they  were  so  uniform  that  they 
absolutely  fixed  the  boundaries  and  relations  of  the 
spaces  and  sheaths.  Moreover,  these  experiments  gave 
results  which,  when  applied  clinically,  were  of  inesti- 
mable value  in  determining  the  course  the  infections 
tended  to  pursue.  Again,  they  determined  not  only 
the  proper  sites  for  opening  any  particular  focus,  but 
also  indicated  where  secondary  abscesses  would  be 
located,  and  thus  favored  early  diagnosis  and  treatment 
of  such  processes.  Furthermore,  they  demonstrated 
the  relation  between  tendon  sheath  abscesses  and 
fascial  space  abscesses.  These  studies  have  been  of 
greater  aid  than  any  other  in  placing  the  treatment 
of  infections  of  the  hand  upon  a  scientific  basis. 

A  brief  outline  of  the  various  procedures  will  be 
of  value  in  preserving  a  general  picture.  This  will  be 
followed  by  a  discussion  of  the  individual  experiments. 

Our  first  group  of  experiments  had  for  its  object  the 
determination  of  the  relation  of  rupture  of  the  synovial 
sheaths  to  the  secondary  abscesses  in  the  fascial  spaces. 


OUTIJM'S  ,l.\l)  1)1  ri.RTICA  l.,l  01    I'.ISCI.II.  SI'.ICI.S      11,") 

In  other  words,  it  an  in  I  eel  ion  l)ci;an  in  a  |)arti(iilar 
tt'iulon  and  rii|)t  iircd  honi  it,  whcrf  would  the  sc-c- 
ondarN  abscess  lie.''  This  was  dclcrnnncd  1)\'  an  cxten- 
si\t'  series  of  i'\i)erinients  iijjon  each  sheath.  (  linical 
evidence  has  aceumuhited  in  ni>'  hands  sunieient  to 
verify  every  one  of  the  experimental  deductions  \vc 
ha\  ('  here  made. 

The  second  |)r()l)leni  dealt  with  determining;  the 
boundaries  and  dix'erticula  of  each  ol  the  dehnite 
spaces  I  have  described.  To  do  this  injecticjns  of  these 
spaces  were  made  from  every  possible  source  of  infec- 
tion— the  tendon  sheaths,  direct  imi)lantation,  and 
extension  from  neighboring  spaces.  The  results  were 
uniform,  as  will  be  seen  by  a  study  of  the  experiments. 

Again,  certain  of  these  injections  were  made  with 
great  force  to  determine  where  pus  w^ould  extend  when 
it  ruj^tured  from  these  indi\iclual  spaces. 

Therefore,  by  these  experiments  we  have  determined 
the  sites  of  extensions  from  the  synovial  sheaths  and 
for  each  fascial  space:  {a)  The  source  of  involvement; 
{b)  the  normal  limitations  of  that  space;  (c)  the  areas 
to  which  pus  will  extend  from  the  space.  Here  again 
clinical  evidence  will  be  later  adduced  to  show  that  all 
of  these  deductions  are  pathologically  correct. 

For  the  sake  of  clearness  is  appended  a  tabulation 
of  these  experiments: 

I.  The  relation  of  rupture  of  the  tendon  sheaths 
to  the  fascial  spaces. 

From  the  tendon  sheath  of  the  middle  finger.  Experi- 
ments I  and  2. 

From  the  tendon  sheath  of  the  ring  fmger,  ExjDeri- 
ments  3,  4,  icS,  19,  and  20. 

From  the  tendon  sheath  of  the  little  fmger,  Kxi:)eri- 
ments  5,  6,  7,  and  47. 

From  the  tendon  sheath  of  the  index  tinger,  Experi- 
ments 8,  9,  27,  and  35. 


116         SYNOVIAL  SHEATHS  AND  FASCIAL  SPACES 

From  the  tendon  sheath  of  the  thumb,  Experiments 
10  to  17. 

II.  The  boundaries  and  diverticula  of  the  spaces. 

(a)  Middle  palmar  space. 

Injection  via  ring  finger  sheath,  Experiments  3,  4, 
18  to  20. 

Injection  via  middle  finger  sheath,  Experiments  i 
and  2. 

Injection  via  little  finger  sheath,  Experiments  5,  6, 
7,  and  47. 

Injection  via  palmar  fascia.  Experiments  21  to  25. 

Injection  via  lumbrical  muscle  space.  Experiments 
26A  and  26B. 

Of  these,  great  force  was  used  in  19,  20,  and  3.  From 
these  and  others  deductions  were  made  as  to  the  loca- 
tion of  pus  extensions  from  the  middle  palmar  space. 

(b)  Thenar  space. 

Injection  via  index  finger  sheath.  Experiments  27 
to  35,  8  and  9. 

Injection  via  palmar  fascia.  Experiments  36,  ^^'j, 
and  38. 

Of  these,  great  force  was  used  in  the  experiments 
from  27  to  35  inclusive,  and  from  the  results  deduc- 
tions were  made  as  to  the  location  of  pus  extensions 
from  the  thenar  space; 

(c)  Dorsal  subcutaneous  space. 

Injection  between  first  and  second  metacarpals. 
Experiments  39  and  40. 

Injection  between  second  and  third  metacarpals, 
Experiments  41  and  42. 

(d)  Dorsal  subaponeurotic  space. 
Experiments  43,  44  and  45. 

.{e)  Hypothenar  space. 
General  results  of  experiments  quoted. 
(/)  Forearm  space. 

Injection  via  flexor  longus  pollicis  sheath,  Experi- 
ments 46,  10  to  17. 


ixjEcriox  III  TExnox  siirrrii  or  middle  eixcer    i  17 

liiji-ction  via  ulnar  Idirsa  and  litllc  Imi^cr,  I'-xpcri- 
nicnts  47  and  50. 

Injccticjii  via  middk-  ])alniar  space,   I'.xj^t riiULiit  49. 

Injection  along  radial  and  ulnar  vessels,  grouped 
under  composite  experinunl  51. 


THE  RELATION  OF  TENDON  SHEATH  RUPTURE  TO  THE 
FASCIAL  SPACES 


Injection  via  the  Tendon  Sheath  of  the  Middle  F"inger 

In  inserting  the  cannula  no  effort  was  made  to  reach 
any   particular  spot,   but  it   was   allowed   to   rupture 


Schematic  drawing  made  from  a  dissection  of  a  hand  injected  from  the 
tendon  sheath  of  the  middle  finger.  The  mass  filled  the  middle  palmar  space 
and  extended  along  the  two  lumbricals. 

through  the  weakest  spot  in  its  course.  It  will  be 
noted  that  in  each  instance  the  mass  entered  and  tilled 
the  middle  palmar  space. 


118         SYNOVIAL  SHEATHS  AND  FASCIAL  SPACES 

Experiment  i. — Left  hand.  Cannula  inserted  into 
tendon  sheath  of  middle  finger  at  the  middle  of  the 
proximal  phalanx,  moderate  force  used  in  injection. 
The  mass  occupied  the  middle  palmar  space  only, 
going  up  to  about  one-half  inch  below  annular  ligament. 
Downward  it  had  returned  along  the  lumbrical  muscles 
of  the  little  and  ring  fingers  nearly  to  the  web  of  the 
fingers.  It  did  not  return  to  any  extent  along  the 
lumbrical  muscles  of  the  middle  finger.  In  every  way 
this  was  a  perfect  representation  of  what  is  probably 
a  typical  collection  in  the  middle  palmar  space.  (See 
experimental  injection  drawing.  Fig.  34.) 

Experiment  2. — Left  hand.  Same  as  No.  i  in  every 
particular.     No  mass  to  radial  side  of  middle  finger. 

Experiment  2A. — Right  hand.  Same  as  No.  i  in 
every  particular. 

Injection  via  the  Tendon  Sheath  of  the  Ring  Finger 

The  tendon  sheath  was  opened  at  the  base  of  the 
finger  and  the  cannula  inserted  in  the  sheath  and  pushed 
through  the  proximal  blind  end  into  whatever  space 
was  at  that  site,  thus  trying  to  demonstrate  where  an 
infection  would  spread  to  if  it  extended  from  the 
tendon  sheath.  In  one  case,  which  is  not  included  in 
the  report,  the  tendon  sheath  did  not  end  blindly, 
but  extended  up  into  the  group  of  tendons  at  the 
wrist.  In  every  case  where  the  sheath  ended  normally 
the  mass  filled  the  middle  palmar  space. 

Experiment  3. — Right  hand.  Moderate  force  used. 
In  this  case  the  mass  occupied  the  middle  palmar 
space  as  it  has  been  described.  No  diverticula  were 
noted  except  that  the  mass  extended  along  the  lum- 
brical muscles  of  the  ring  finger  for  about  one-half 
inch.     (See  experimental  injection  drawing.  Fig.  35.) 

Experiment  4. — Right  hand.  Moderate  force  used. 
In  this  case  the  cannula  broke  from  the  blind  end 


I'K'-  .^5 


Schematic  drawing  made  from  a  dissection  of  a  hand  injected  along  the 
icndon  sheath  of  the  ring  finger.  The  mass  filled  the  middle  palmar  space, 
with  extension  along  the  lumbrical  muscle. 

Fig.  36 


Schematic  drawing  made  from  a  dissection  of  a  hand  in  wliich  the  mass 
was  injected  from  the  tendon  sheath  of  the  middle  finger  and  filled  the  loft 
over  the  middle  palmar  space,  but  did  not  rupture  into  it. 


120  SYNOVIAL  SHEATHS  AND  FASCIAL  SPACES 

evidently  superficial  to  the  tendon,  for  there  was  a 
small  mass  only,  lying  superficial  to  the  tendon,  about 
a  quarter  of  an  inch  wide  and  three-quarters  of  an  inch 
long.  It  had  not  involved  the  middle  palmar  space, 
but  it  was  seen  that  the  thinnest  wall  was  in  relation 
to  that  space,  and  in  case  of  infection  the  pus  would 
have  extended  into  it  in  all  probability.  (See  experi- 
mental injection  drawing.  Fig.  36.)  This  is  further 
supported  by  Experiments  18,  19,  and  20  (g.  v.). 


Injection  via  the  Tendon  Sheath  of  the  Little  Finger 

The  injections  5  and  6  demonstrate  where  the  pus 
will  lie  in  those  cases  in  which  the  rupture  takes  place 
in  the  hand,  namely,  the  middle  palmar  space.  It 
may  also  rupture  in  the  forearm.  In  fact,  that  is  its 
most  frequent  site.  The  location  of  the  pus  in  the 
latter  case  will  be  seen  by  studying  Experiment  47. 

Experiment  5. — During  an  attempt  to  inject  the 
ulnar  sheath  in  the  right  hand  it  was  found  to  be 
obliterated  at  the  phalangometacarpal  articulation. 
The  cannula  broke  out  into  a  space  which  was  injected 
with  moderate  force,  and  upon  dissection  the  middle 
palmar  space,  as  already  described,  was  found  filled 
with  the  mass.  It  had  not  gone  up  into  the  wrist,  over 
into  the  thenar  or  hypothenar  areas,  but  had  returned 
along  the  lumbrical  muscles  of  the  little,  ring,  and 
middle  fingers.      (See  experimental  injection  drawing, 

Fig-  37.) 

Experiment  6. — In  another  attempt  to  inject  the 
ulnar  bursa  with  moderate  force,  the  injection  was 
arrested  at  the  annular  ligament  owing  to  the  rigidity 
of  the  tissue  of  the  subject.  Due  to  this  fact  and  the 
friability  of  the  tissues  incident  to  age,  the  ulnar  bursa 
ruptured  at  about  the  middle  of  the  palm,  and  the  mass 


Fu:.  37 


Schematic  drawing  made  from  a  dissection  of  a  hand  injected  from  the 
tendon  sheath  of  the  Httle  finger  with  which  the  ulnar  bursa  did  not  connect. 
The  mass  ruptured  into  the  middle  palmar  space,  filling  it,  with  prolonga- 
tions along  three  lumbrical  muscles. 

Fig.  38 


Schematic  drawing  made  from  a  dissection  of  a  hand  in  which  the  mass 
was  injected  along  the  tendon  sheath  of  the  little  finger;  closure  at  the  upper 
end  of  the  annular  ligament  of  the  ulnar  bursa  allowed  rupture  from  the 
ulnar  bursa,  the  mass  filling  the  middle  palmar  space,  with  extension  along 

one  lumbrical  muscle. 


122         SYNOVIAL  SHEATHS  AND  FASCIAL  SPACES 

was  found  to  occupy  the  middle  palmar  space  only, 
in  addition  to  the  ulnar  bursa  sheath  of  the  tendons. 
The  mass  returned  along  the  ring  finger  lumbrical 
only.  The  surgical  importance  of  this  experiment  is 
readily    seen.      (See   experimental    injection    drawing 

Fig.  38). 

Experiment  7. — Here  we  have  the  result   produced 
in  those  cases  in  which  the  rupture  is  in  the  forearm 
and  not  in  the  hand.    The  x-ray  photograph  here  pre- 
sented, which  is  made  from  the  hand  injected  in  Experi- 
ment 7,  presents  a  clear  picture  of  the  bones  in  their 
relation  to  the  injected  bloodvessels  and  ulnar  bursa 
(Fig.    39).      Upon   this   plate   have   been   placed   lines 
which    represent    the    boundaries    of    the    thenar    and 
middle   palmar  spaces.     The  numerous  parallel  lines 
at   the   distal   end   of   the   palm   represent   the   dense 
tissue  here  overlying  the  articulation,  in  which  there 
are   no   spaces   except   those   made   by   the   lumbrical 
muscles   with   the  vessels,  and    the   synovial   sheaths. 
(See  cross-section.  Fig.  22.)     Three  curved  lines  show 
the  position  of  the  flexion  creases  of  the  palm  of  the 
hand,  and  in  relation  to  these,  note  that  the  proximal 
end  of  the  distal  flexion  crease  corresponds  with  the 
beginning  of  the  dense  tissue  noted.     Again,  note  that 
the  distal  end  of  the  middle  flexion  crease  also  begins 
at  the  dense  tissue,  and  hence  a  line  drawn  between 
these   two    points   limits   the    palmar   spaces   distally. 
Pay  particular  attention  to  the   point  at  which   this 
middle   flexion   crease   crosses   the   space   between   the 
metacarpal  bones  of  the  middle  and  ring  fingers,  at 
the  distal  end  of  the  middle  palmar  space,  avoiding  the 
thenar   space   upon   the   radial   side,    the   ulnar   bursa 
upon  the  ulnar  side,  the  dense  tissue  distally,  and  the 
deep   palmar  arch  which  is  seen   crossing  the   upper 
part   of  the   middle   palmar  space   proximally.      Note 
that  although  the  injection  mass  has  broken  from  the 


inje(:tI()\  11. 1  TKxnox  siik.itii  or  i.itti.k  fisc.kr    vn 

ulnar  slicalh  in  the  loicarni,  \ct  the  sj)a(('s  in  the  hand 


arc  unnno 


Kcd. 


Fig.  39 


A'-ray  Plate.  Boundaries  of  the  thenar  and  middle  palmar  spaces  marked 
and  proper  site  for  opening  the  latter  indicated.  Ulnar  bursa  and  blood- 
vessels injected.  Photograph  made  for  me  Ijv  Dr.  Cul)bins'  Surgical  A'-ray 
Laboratory. 

Expcrimoits  54  to  58. — In  these  as  with  many  other 
experiments,  the  records  of  which  arc  not  here  reported, 


124 


SYNOVIAL  SHEATHS  AND  FASCIAL  SPACES 


the  mass  ruptured  at  the  proximal  end  of  the  sheath 
under  the   flexor  profundus  tendons  in  the  forearm 
This  is  the  most  common  site  of  extension.    (See  Experi- 
ment 50  for  a  complete  description  of  these  cases.) 

Injection  via  the  Tendon  Sheath  of  the  Index  Finger 

Here  the  findings  are  positive.     In  addition  to  the 
experiment  here  detailed,  many  others  were  performed 

Fig.  40 


Schematic  drawing  made  from  a  dissection  of  a  hand  injected  along  the 
tendon  sheath  of  the  index  finger.  Mass  filled  thenar  space  and  extended 
around  to  the  dorstim  underneath  adductor  transversus  and  also  along  lum- 
brical  muscle. 

which  gave  the  definite  information  that  when  pus 
ruptures  from  this  sheath  it  enters  the  thenar  space. 
Experiment  8. — Injection  was  made  through  the 
tendon  sheath  of  the  index  finger.  The  mass  occupied 
the  thenar  space ;  did  not  go  into  the  forearm  or  middle 


INJECTION  ri.l   THE  ILKXOR  LONGUS  I'OI.IJCIS     125 

palmar  space.  Passed  around  the  lower  or  distal  edge 
of  the  addiKior  transversus,  filled  a  space  the  size  of 
a  walnut  between  that  nuiscle  and  the  lirst  dorsal 
interosseous,  and  abutted  on  the  dorsal  subcutaneous 
tissue  at  wTb.  Followed  index  lumbrical  only.  (See 
experimental  injection  drawing,   Fig.  40.) 

Experiment  9. — Same   findings  as  in   Experiment  8. 

Experiments  24  to  30  and  29  to  35  corroborate  these 
findings. 

Injection  via  the  Tendon  Sheath  of  the  Flexor  Longus 
pollicis 

Here  one  would  expect  the  mass  to  enter  the  thenar 
space  in  the  hand,  and  we  were  therefore  surprised  to 
find  that  this  was  not  generally  the  case.  To  deter- 
mine this  point  definitely,  eight  experiments  were  made. 
In  each  case  great  pressure  was  used  in  the  injection. 
The  cannula  w^as  inserted  into  the  tendon  sheath  in  the 
thumb  and  so  bound  that  the  mass  could  not  escape 
around  the  needle.  These  experiments  showed  that 
in  a  majority  of  cases  the  rupture  took  place  in  the 
forearm  under  the  flexor  profundus  digitorum.  It  did 
at  times,  however,  rupture  distal  to  the  annular  liga- 
ment and  fill  the  thenar  and  even  the  middle  palmar 
spaces. 

Experiment  10. — A  cannula  was  inserted  into  the 
sheath  of  the  flexor  longus  pollicis  at  the  thumb.  The 
injection  mass  was  found  to  have  filled  completely  the 
bursa,  including  the  part  proximal  to  the  annular 
ligament.  The  mass  had  ruptured  from  the  proximal 
end  and  passed  up  into  the  forearm.  No  extravasation 
had  taken  place  into  the  hand,  either  by  direct  rupture 
or  retrograde  extension.  The  attachment  of  the  flexor 
longus  pollicis  at  its  origin  had  been  torn  in  part  from 
the  bone.     The  mass  extended  up  along  this  muscle 


126  SYNOVIAL  SHEATHS  AND  FASCIAL  SPACES 

on  the  radial  side  of  the  forearm,  having  on  its  ulnar 
boundary  and  roof  the  flexor  profundus  digitorum  and 
the  flexor  sublimis  digitorum.  The  major  portion  of 
the  mass  was  found  under  the  flexor  profundus  digi- 
torum, going  over  even  to  the  flexor  carpi  ulnaris. 
It  filled  an  area  extending  from  the  wrist- joint  to  within 
three  inches  of  the  elbow-joint. 

Experiment  ii. — The  findings  here  were  practically 
the  same  except  that  a  small  part  of  the  mass  passed 
downward  under  the  annular  ligament  and  the  ulnar 
bursa  to  fill  partially  the  middle  palmar  space.  This, 
however,  would  probably  not  occur  in  an  inflammatory 
case  owing  to  the  small  channel  present. 

Experiment  12. —  In  this  case  the  mass  ruptured 
from  the  upper  third  of  the  synovial  sheath,  just 
distal  to  the  annular  ligament.  It  extended  downward 
to  the  thenar  space  and  partially  filled  it.  A  small 
part  had  also  entered  the  upper  end  of  the  palmar 
space,  owing  to  the  indefinite  septum  separating  these 
spaces  at  the  upper  end.  The  large  mass,  however, 
was  in  the  thenar  space,  but  it  demonstrated  that 
extension  into  the  middle  palmar  space  would  be  pos- 
sible in  neglected  cases. 

Experiments  13,  14,  15,  and  16. — These  were  prac- 
tically duplicates  of  the  above  results. 

Experiment  17. — In  this  case  there  was  apparently 
a  free  anatomical  communication  between  the  ulnar 
and  radial  bursa,  for  the  mass  filled  the  ulnar  bursa. 
There  was  also  an  extension  into  the  forearm  from  a 
rupture  of  the  proximal  end  at  the  radial  bursa. 


General  Deductions  as  to  Relation  or  Tendon  Sheaths  to 

Fascial  Spaces 

The  injections  through  the  synovial  sheaths  of  the 
tendons  of  the  ring  and  middle  fingers  passed  into  the 


THE  MIDDLE  J'.ILM.IR  SP.ICE  127 

middle  i);ilm;ir  space,  while  thai  space  was  reached 
also  ironi  llu'  little  liiiLiei-  in  those  cases  where  the 
synovial  sheath  was  distinct  from  the  ulnar  hiirsa; 
and,  indeed,  the  contents  of  tile  ulnai'  l)ursa  itself, 
when  it  ruptured  into  the  j)alm,  entered  the  same  space. 
Injection  masses  from  the  index  syn(^vial  sheath  passed 
into  the  thenar  space.  In  those  cases  where  the 
synoxial  sheath  ol  either  ol  these  lingers  communi- 
cated with  the  ulnar  hursa,  the  mass  passed  into  that, 
and  followed  the  course  of  any  bursal  injecti(Mi.  The 
extreme  rarit>'  of  communication  between  the  index 
synovial  sheath  and  the  ulnar  bursa  robs  that  point 
of  any  surgical  interest  such  an  anomaly  would  have. 
A  mass  from  the  radial  bursa  or  the  synovial  sheath 
of  the  flexor  longus  pollicis,  if  it  ruptures  into  the  hand, 
will  lie  in  the  indefinite  spaces  mentioned  as  lying 
directly  over  the  muscles  of  the  metacarpal  bone  of 
the  thumb.  It  is  possible  for  it  to  erode  into  the  thenar 
space,  but  it  is  more  likely  to  rupture  into  the  fascial 
spaces  of  the  forearm  and  lie  under  the  flexor  profundus 
digitorum.  The  ulnar  bursa  may  rupture  into  the 
middle  palmar  space  and  it  will  almost  surely  rupture 
into  the  forearm  under  the  flexor  profundus  digitorum. 

THE    XORAIAL    BOUNDARIES    OF    THE    FASCIAL    SPACES    AXD 

THE    POSITION    OF    SECONDARY    ABSCESSES    IN    CASE    OF 

EXTENSION  FROM  THE  SPACES 

The  Middle  Palmar  Space 

Injection  via  the  Tendon  Sheath  of  the  Ring 
Finger. — Experiment  i8. — Left  hand,  along  tendon 
sheath  of  ring  finger;  the  mass  was  injected  with  con- 
siderable force.  The  middU^  palmar  space  as  described 
was  filled.  Thenar  and  hypothenar  area  free,  mass 
followed  along  little  and  ring  finger  lumbricals  for 
three-fourths  inch,  none  along  other  fingers,  none 
through  between  bones  to  back,  mass  extendi d  under 


128         SYNOVIAL  SHEATHS  AND  FASCIAL  SPACES 

tendons  strictly,  up  into  forearm,  where  a  large  mass 
was  found  lying  under  the  deep  muscles  upon  the 
pronator  quadratus  and  the  interosseous  septum  up 
to  the  pronator  radii  teres.  The  mass  came  to  the 
surface  late  upon  the  radial  side,  about  two  inches 
above  wrist,  but  the  mass  was  most  marked  upon  the 
ulnar  side  from  above  downward,  between  the  flexor 
carpi  ulnaris  and  the  deep  tendons  and  muscles.  The 
importance  of  the  position  of  this  mass  from  a  clinical 
standpoint  can  be  seen. 

Experiment  19. — Same  findings  as  in  Experiment  18. 

Experiment  20. — Wrist  bound  tightly  above  annular 
ligament;  cannula  inserted  along  ring  finger  synovial 
sheath,  and  mass  injected  with  great  force,  the  idea 
being  to  see  where  the  mass  would  rupture  in  case 
that  means  of  exit  was  closed.  None  of  the  mass  went 
to  the  forearm  or  dorsum,  but  did  rupture  into  the 
thenar  space  at  the  upper  or  proximal  end  of  the 
intervening  septum  and  filled  the  thenar  space,  passed 
along  all  lumbrical  muscles  into  canals  for  a  consider- 
able distance,  but  not  out  into  the  web  between  the 
fingers.     (See  experimental  injection  drawing,  Fig.  41.) 

Experiments  3  and  4  corroborate  these  findings. 

Experiments  1,2,  and  3,  in  which  the  space  was  in- 
jected from  the  middle  finger,  and  Experiments  5  and  6, 
in  which  the  space  was  injected  from  the  little  finger, 
present  the  same  findings  as  in  Experiments  18,  19, 
and  20. 

Injection  through  the  Palmar  Fascia. — ^^Injec- 
tion  of  the  space  by  inserting  a  needle  through  the  palm 
directly  into  the  space  gives  the  results  uncomplicated 
by  any  other  process. 

Experiment  2i.-^Left  hand.  Cannula  inserted 
through  the  palmar  fascia  where  middle  flexion  crease 
crosses  metacarpal  space  between  ring  and  middle 
fingers.     Moderate  force  used. 


77//;   MIDDLE   />.//. .\f.lR  SI'.ICE 


129 


Note. — (^arc   nuisl   be  taken  that    tin-  cannula  j<oes 

dorsal  to  the  tcMidons,  /".  r.,  really  into  spare,  otherwise 

the  mass  will  he  conrnied  to  the  imperfect  spaces  around 

the  tendons,  particularK-  su])erricial  to  them.      I^\en  if 

this  should  occur,  if  great  force  is  used,  it  will  rupture 

into  the  great  space;  not  so  readily,  however,  as  would 

pus,  since  the  erosive  action  of  the  latter  is  not  present 

in  simple  injections. 

Fig.  41 


Schematic  drawing  made  from  a  dissection  of  a  hand  in  which  the  injec- 
tion was  made  along  the  tendon  sheath  of  the  ring  finger  under  great  force. 
The  mass  filled  middle  palmar  and  thenar  spaces,  with  extension  along  all 
lumbrical  muscles. 

Upon  dissection  the  mass  was  found  to  be  limited 
to  what  we  have  found  in  the  middle  palmar  space. 
It  was  limited  upon  the  radial  side  by  the  attachment 
of  fascia  to  the  middle  metacarpal  bone.  This  was  the 
long  leg  of  the  right-angle  triangle.  The  ulnar  side 
represented  the  hypotenuse  of  the  triangle  lying  to 
the  radial  side  of  the  hypothenar  space.  The  apex  of 
9 


130         SYNOVIAL  SHEATHS  AND  FASCIAL  SPACES 

the  triangle,  or  the  highest  point  to  which  the  mass 
spread,  was  about  one  inch  distal  to  the  distal  flexion 
crease  of  the  wrist,  or  about  a  finger's  breadth  proximal 
to  a  line  drawn  transversely  across  the  palm  from  the 
web  of  the  extended  thumb. 

At  the  lower  part  of  the  palm,  i.  e.,  toward  the  web 
of  the  fingers,  the  greater  part  of  the  mass  was  limited 
by  a  line  drawn  between  the  radial  end  of  the  middle 
flexion  crease  and  the  ulnar  end  of  the  distal  flexion 
crease  of  the  palm,  or,  roughly  speaking,  about  a 
thumb's  breadth  above  the  web  of  the  fingers;  this  is 
the  short  leg  of  our  right-angle  triangle  A  prolonga- 
tion of  the  mass  had  taken  place,  however,  along  the 
lumbrical  muscle  between  the  middle  and  ring  fingers, 
going  almost  to  the  web  of  the  fingers.  There  was  no 
appreciable  mass  along  the  other  lumbrical  muscles, 
although  some  of  the  stain  from  the  methylene  blue 
used  in  the  injection  mass  had  stained  the  space 
around  the  muscle  leading  to  the  little  finger.  No 
other  prolongations  were  present.  It  did  not  break 
into  the  interossei  muscles  or  superficially  about  the 
tendons.  Superficial  palmar  vessels  crossed  upper  part 
of  mass.    (See  experimental  injection  drawing.  Fig.  42.) 

Experiment  22. — Left  hand.  Injection  at  the  same 
point  and  in  the  same  manner  as  No.  21.  The  mass 
here  occupied  exactly  the  same  area  of  distribution 
as  in  Experiment  21,  except  the  mass  as  a  whole  was 
not  so  large,  being  a  little  larger  than  an  almond.  The 
most  prominent  part  of  the  mass  was  in  the  middle 
of  the  palm,  over  the  middle  metacarpal  space.  There 
were  slight  prolongations  distally  along  the  lumbrical 
muscle  between  ring  and  middle  metacarpals  as  above. 

Experiment  23. — Injection  made  same  as  in  Experi- 
ment 21.  Both  x-ray  picture  and  dissection  made  of 
this  right  hand.  Mass  extended  somewhat  higher  in 
the  hand  than  in  Experiment  21,  going  to  a  point  about 


'/•///•;  MI  1)1)1.1:  p.iLM.ik  sr.icE  \:\\ 

a  finder's  breadth  below,  i.  e.,  distal  to  the  distal 
Hexion  crease  of  the  wrist  Kinp:  dorsal  to  the  tendon 
group;  laleralK  its  boundaries  were  the  same,  while 
at  the  distal  i)ortiou  of  the  palm  a  i)roIont;at ion  of  the 
mass  occurred  along  the  lumbrical  muscles  gfjing  to  the 
little,  ring,  and  middle  tingers.  This  is  of  c(jnsiderable 
importance,  since  it  is  remembered  that  the  relation 
of   the   lumbrical    muscle  of   the   middle   finger  to  the 

Fig.  42 


Schematic  drawing  made  from  a  dissection  of  a  hand  in  which  the  injec- 
tion was  made  through  the  palmar  fascia  into  the  middle  palmar  space. 
The  mass  filled  middle  palmar  space,  with  extension  along  one  lumbrical 
muscle. 

middle  palmar  space  was  discussed  in  the  division 
devoted  to  cross-sections,  and  this  experiment  bears 
out  the  assumption  hazarded  there  that  this  muscle 
space  \vas  really  a  diverticulum  of  the  middle  palmar 
space  and  not  of  the  thenar  space.  (See  cross-sections, 
Figs.  2T)  and  24.) 

Experiment    24. — Injection     left    hand,    same    as    in 
Experiment    21.      Mass    occupied    same    space    as    in 


132 


SYNOVIAL  SHEATHS  AND  FASCIAL  SPACES 


Experiment  21,  except  that  mass  spread  down  along 
lumbrical  muscle  of  little  and  ring  fingers  for  a  distance 
of  one-third  inch. 

Injection  through  Palmar  Fascia  into  Middle 
Palmar  Space. — Experiment  25  (see  x-ray  photograph, 
Fig.  43). — This  hand  was  also  dissected.     It  represents 

Fig.  43 


X-ray  plate  made  from  a  hand  in  which  the  middle  palmar  space  was 
injected  with  a  mixture  of  red  lead  and  plaster  of  Paris.  Photograph  repre- 
sents location  of  pus  in  typical  middle  palmar  space  infection. 

how  the  mass  extends  down  along  the  lumbrical 
muscles,  and  shows  also  what  site  should  be  opened 
to  evacuate  the  contents  of  the  space.  Note  that  the 
hypothenar  and  thenar  regions  are  uninvolved,  the 
mass  not  extending  to  the  radial  side  of  the  middle 
metacarpal.  It  is  seen  that  the  ulnar  bursa  would 
lie  over  the  ulnar  side  of  the  mass. 


THE  Tin: N.I R  sricE 


133 


Injection  Along  Lumi'.kk  al  Muscli-:  oi-  KiNci 
Finger. — Experiment  26A. — Cannula  inserted  along 
lumbrical  muscle,  left  hand.  Some  difficulty  was 
experienced  in  the  insertion,  but  when  successful  the 
mass  occupied  the  middle  palmar  space.  There  w^as 
no  return  along  the  lumbrical  muscles.  Moderate 
force  used  in  injection.  (See  experimental  injection 
drawing,  Fig.  44.) 

Fig.  44 


Schematic  drawing  made  from  a  dissection  of  a  hand  in  which  the  injec- 
tion was  made  along  the  lumbrical  muscle  space  between  middle  and  ring 
fingers.    Middle  palmar  space  filled. 

Experimejit  26B. — Right  hand.  Same  technique, 
injection  mass  lies  along  lumbrical  muscle.  Middle 
palmar  space  only  partly  filled. 


The  Thenar  Space 


Note. — The  first  injections  of  this  space  were  very 
unsatisfactory,  owing  to  two  errors  in  technique,  which 
were  corrected  later.     In  the  first  place,  the  injections 


134         SYNOVIAL  SHEATHS  AND  FASCIAL  SPACES 

were  not  made  deep  enough;  and  secondly,  they  were 
too  far  to  the  radial  side  over  the  thumb.  It  is  true 
that  the  results  obtained  by  these  injections  were 
instructive  in  that  they  served  to  show  indefinite 
Hmited  spaces  at  these  sites,  but  they  did  not  reach 
the  large  space  under  consideration. 

Fig.  45 


Schematic  drawing  made  from  a  dissection  of  a  hand  in  which  the  injec- 
tion was  made  along  the  tendon  sheath  of  the  index  finger.  Mass  filled 
thenar  space  and  extended  to  dorsum  between  adductor  transversus  and 
adductor  obliquus. 

Injection  via  the  Tendon  Sheath  of  the  Index 
Finger. — Experiment  2J. — Right  hand.  Cannula  in- 
serted into  tendon  sheath  about  middle  of  proximal 
phalanx  and  ruptured  from  sheath  at  its  proximal  end. 
Moderate  force  used  in  injection.  The  mass  when 
dissected  out  showed  the  limitations  of  the  thenar  space 
as  described.  The  mass  passed  up  dorsal  to  the  tendon, 
to  a  thumb's  breadth  below  the  annular  ligament. 
It  did  not  go  to  the  ulnar  side  of  the  middle  metacarpal. 


'/■///■;   TIIEX.IR  SPACE  135 

'\\\v  mass  laid  direct  l\  upon  the  addiictoi-  Iransversus. 
Il  did  not  ,l;o  aloiii;  the  lunihiical  nuisclc  to  the  side 
of  the  index  finder.  It  did  not  spread  around  undor 
the  web  ol  tlic  thuiiih  lo  ihe  dorsum  of  the  hand,  l)Ut 
was  limited  at  the  distal  border  of  the  adductor  trans- 
\'ersus.  1 1  did  si)read  to  tlie  I)ack,  however,  at  the 
up[)er  or  proximal  edge  of  the  adductor  transversus, 
going  between  the  adductor  transversus  and  the  adduc- 
tor obliquus,  thus  lying  between  the  adductor  trans- 
versus and  the  first  dorsal  interosseous,  at  the  distal 
edge  of  \\hi(-h  it  came  to  he  in  the  subcutaneous  tissue 
of  the   dorsum.     (See  experimental  injection   drawing, 

Fig.  45-) 

Experiment  2S. — Injection  same  as  Experiment  27. 
Here  the  mass  did  not  fill  the  space  completely,  but  did 
return  along  the  lumbrical  muscle  to  the  radial  side 
of  the  index  finger;  condition  well  marked.  For  clinical 
purposes,  Experiments  27  and  28  should  be  studied 
together.  The  probability  is  that  the  cannula  did  not 
rupture  entirely  into  the  space,  but  did  get  out  of  the 
synovial  sheath  into  the  indefinite  spaces  in  the  loose 
connective  tissue  about  the  tendon  in  the  loft,  as  it 
were,  of  the  thenar  space.  (See  experimental  injection 
drawing.  Fig.  46.) 

Injection  of  the  Thenar  Space  under  Forcible 
Pressure. —  The  index  synovial  sheath  was  opened 
and  cannula  forced  out  of  the  proximal  end  into  the 
palm;  forcible  pressure  with  force  pump  was  main- 
tained for  from  three  to  five  minutes.  Owing  to  the 
fact  that  the  routes  of  extension  from  the  thenar  space 
were  somewhat  difficult  to  determine  accurately,  nine 
injections  of  the  space  were  made,  with  the  following 
results.  In  none  of  the  cases  did  the  mass  go  up  into 
the  forearm.  In  3  cases  only  did  it  go  into  the  middle 
palmar  space.  In  8  cases  the  mass  passed  dorsal  to 
the  adductor  transversus;  of  these,  in  6  the  mass  went 


136         SYNOVIAL  SHEATHS  AND  FASCIAL  SPACES 

to  the  dorsum  between  the  adductor  transversus  and 
the  adductor  obHquus,  and  in  4  passed  below  or  distal 
to  the  adductor  transversus  to  lie  between  the  trans- 
versus and  first  dorsal  interosseous.  In  no  case  did 
the  mass  pass  to  the  dorsum  between  the  second  and 
third  metacarpals. 

Fig.  46 


Schematic  drawing  made^from  a  dissection  of  a  hand  in  which  the  injec- 
tion was  made  along  the  tendon  sheath  of  the  index  finger.  Mass  filled  the 
thenar  space  and  extended  along  the  lumbrical  muscle. 

Experiment  29. — Left  hand.  Tissues  well  preserved; 
mass  here  occupied  thenar  space,  and  spread  between 
adductor  transversus  and  adductor  obliquus  to  fill 
space  size  of  a  walnut  between  them  and  first  dorsal 
interosseous;  also  ruptured  through  tissues  between 
thenar  space  and  middle  palmar  space  at  the  proximal 
end  of  the  septum,  passed  over  to  fill  the  middle  palmar 
space,  and  accompanied  the  four  lumbricals  into  their 
respective  canals.  Did  not  go  under  tendons  to  fore- 
arm. 


TIIF.    TIIFA'.IR  SI'. ICE 


137 


ExpcrinK'nts  t^o,  ,^  i ,  and  ,^2  were  ihc  saiiK-  as  Ex- 
jX'rinu'iU  29,  e'xcept  tliat  ihc  mass  in  T)2  did  not  invade 
the  middle  palmar  space.  All  went  above  the  adductor 
transversus  to  dorsum,  however.  The  mass  in  31 
passed  along  middle  finger  lumbrical  and  came  to  lie 
in  the  tissue  of  the  web  immediately  beneath  the  web. 
(See  experimental  injection  drawing,  Fig.  47.) 

Fig.  47 


Schematic  drawing  made  from  a  dissection  of  a  hand  in  which  the  injec- 
tion was  made  along  the  tendon  sheath  of  the  index  finger.  Mass  filled  the 
thenar  space  and  extended  over  to  the  middle  palmar  space,  along  all  the 
lumbrical  muscles,  and  went  to  the  dorsum,  first  between  the  adductor 
transversus  and  obliquus,  and  secondly  between  the  index  and  middle  fingers. 
(See  Fig.  125  for  explanation  of  this  latter  extension.) 


Experiment  33. — This  mass  extension  was  extremely 
interesting.  It  filled  the  thenar  space  and  then  passed 
to  the  space  between  the  adductor  transversus  and  the 
first  dorsal  interosseous,  going  both  above  and  below 
the  adductor,  i.  e.,  both  proximal  and  distal,  abutting 
on  dorsal  subcutaneous  tissue  at  web  at  distal  edge  of 


138 


SYNOVIAL  SHEATHS  AND  FASCIAL  SPACES 


first  dorsal  interosseous,  extended  along  index  lumbrical 
canal,  and  did  not  go  into  middle  palmar  space  or  fore- 
arm. The  most  interesting  extension,  however,  was  that 
which  occurred  through  the  palmar  aponeurosis  at  the 
distal  edge  of  the  bases  of  the  index  and  middle  fingers 
into  the  soft  pad  of  fatty  tissue  which  lies  here  in  the 
palm,  thus  giving  corroboration  to  those  clinical  cases 

Fig.  48 


Schematic  drawing  made  from  a  dissection  of  a  hand  in  which  the  injec- 
tion was  made  along  the  tendon  sheath  of  the  index  finger.  The  mass  filled 
the  thenar  space,  extended  to  the  dorsum  below  the  adductor  transversus 
and  to  the  palm  through  a  defect  of  the  palmar  fascia. 


which  are  on  record  in  which  pus  has  pointed  here, 
supposedly  through  an  imperfect  palmar  fascia.  This 
was  the  only  experimental  injection  in  which  a  mass 
appeared  in  the  palm.  (See  experimental  injection 
drawing.  Fig.  48.) 

Experiment  34. — Result  same  as  33  except  no  sub- 
dermal  palmar  extension. 


THE   Til  EX. Ik  S/'./CE 


l.'iO 


/''.xprriniciil  ^^5.  Mass  Tilled  thenar  s|)ac(';  no  cx- 
ICMisioiis  excepl  aloiiL;,  index  liinil  )ri(al  canal. 

InjI'XTion  TiiRoi(iii  Palmar  Fascia  in  Attempt 
TO  Reach  Thenar  Space. — To  do  this  j^ropcrly  the 
cannuhi  should  \)v  inserted  about  the  middle  line  of 
the  jxilni  one  ctMilinieler  to  the  tlienar  side  of  the  adduc- 
tion Hexion  crease  of  the  thnnib. 

I'^IG.  49 


Schematic  drawing  made  from  a  dissection  of  a  hand  in  which  the  injection 
was  made  through  the  pahnar  fascia  into  the  thenar  space. 


Experiment  36. — Left  hand.  Cannula  inserted  into 
middle  thenar  space,  moderate  force  used  in  injection. 
Mass  was  found  to  have  filled  the  space  completely, 
but  had  not  followed  along  the  index  lumbrical  muscle 
to  the  finger,  nor  had  it  gone  to  the  dorsum  under  the 
subcutaneous  tissue.  The  space  filled  corresponded  to 
the  area  comprised  between  the  adduction  crease  of 
the  thumb  and  the  metacarpal  bone  of  the  thumb 
in  adduction.  (See  experimental  injection  drawing, 
Fig.  49.) 


140 


SYNOVIAL  SHEATHS  AND  FASCIAL  SPACES 


Experiment  37. — Attempt  to  inject  thenar  space. 
Right  hand.  Cannula  was  inserted  too  far  to  radial 
side  over  muscular  group.  Small  mass  was  foultid  in 
indefinite  space  adjacent  to  flexor  brevis  pollicis.  (See 
experimental  injection  drawing,  Fig.  50.) 

Experiment  38. — Same  as  Experiment  37. 

Fig.  50 


Schematic  drawing  made  from  a  dissection  of  a  hand  in  which  an  attempt 
was  made  to  inject  the  thenar  space  but  in  which  the  cannula  reached  only 
one  of  the  indefinite  spaces  near  the  metacarpal  bone. 


The  Dorsal  Subcutaneous  Space 


Injection  of  Subcutaneous  Tissue  of  the.  Dor- 
sum BETWEEN  the  .First  and  Second  Metacarpals. 
— Note. — These  injections  were  made  to  determine  the 
relation  of  these  spaces  to  the  thenar  space  and  the 
remainder  of  the  subcutaneous  tissue  on  the  dorsum. 

Experiment  39. — Injection  right  hand.  Moderate 
force;  insertion  into  subcutaneous  tissue  on  dorsum, 
thenar  region.     Mass  was  found  to  be  subcutaneous, 


'/■///•;  DORS.  1 1.  scficrr.fNEOus  space  hi 

and  wliik'  iIutc  was  f\  idiiulv'  a  U-ikIcikn  to  limilalioii 
at  the  index  metacarpal,  yet  it  is  doiihtful  if  it  was  due 
to  tile  attachment  ol  fascia  to  the  l)oiic,  hcini;  more 
likely  to  be  the  natural  tendency  to  limitation  found 
in  the  meshes  of  any  loose  tissue.  Moreover,  in  spite 
of  the  partial  limitation  at  this  point,  it  had  spread  into 
the  subcutaneous  tissue  above  the  tendons  going  from 
the  wrist  proximalh'  to  the  metacarpophalangeal  articu- 
lation distally  and  over  to  the  level  of  the  fourth  meta- 
carpal bone.  It  did  not  go  through  to  the  palm  by  an>' 
channel. 

Experiment  40. — Injection  of  left  hand  same  as 
above.  Mass  upon  dissection  found  to  occupy  dorsal 
thenar  subcutaneous  tissue  over  to  the  index  meta- 
carpal, beyond  which  it  did  not  extend.  It  did  not 
pass  to  the  palmar  surface  nor  into  the  thenar  space. 

Injection  of  the  Subcutaneous  Tissue  of  the 
Dorsum  between  Second  and  Third  Metacarpal 
Bones. — Experiment  41. — Right  hand.  Cannula  in- 
serted into  subcutaneous  tissue  of  dorsum  of  hand  and 
the  mass  injected  with  considerable  force.  The  tip  of 
the  needle  was  superficial  to  the  tendons  but  deeper 
than  the  superficial  layers  immediately  beneath  the 
skin.  Upon  dissection,  mass  found  to  occupy  a  con- 
siderable space  extending  from  the  wrist  above  to 
the  metacarpophalangeal  articulation  below  and  from 
the  metacarpal  bone  of  the  index  finger  to  the  meta- 
carpal bone  of  the  little  finger;  proximally  and  distally, 
at  the  wTist  and  fingers  respectively,  the  tissue  seemed 
to  be  bound  more  firmly  to  the  underlying  tissue  than 
laterally. 

ExperimeM  42. — Left  hand.  Technicjue  and  results 
same  as  Experiment  41.  A  study  of  these  two  show 
several  layers  of  fascia  between  the  skin  and  tendons, 
with  no  single  space  more  distinct  than  another. 


142 


SYNOVIAL  SHEATHS  AND  FASCIAL  SPACES 


The  Dorsal  Subaponeurotic  Space 

Injection  under  Tendons  of  Dorsum.  —  The 
importance  of  this  series  is  seen  when  we  remember 
that  it  is  in  this  space  that  pus  would  he  if  it  ruptured 
through  between  the  metacarpals  from  the  palmar 
surface.    The  results  obtained  were  uniform. 

Fig.  51 


Schematic  drawing  made  from  a  dissection  of  a  hand  in  which  the  injec- 
tion was  made  underneath  the  aponeurosis  of  the  dorsum,  the  subaponeurotic 
space  being  filled. 


Experiment  43. — Left  hand.  Cannula  tip  inserted 
under  tendons  between  middle  and  ring  fingers  at  lower 
third  of  dorsum.  Considerable  force  was  used  in  the 
injection.  The  mass  was  confined  to  the  space  under 
the  tendons,  i.  e.,  was  covered  by  the  tendons  and  the 
aponeurosis  between  them.  It  passed  up  to  the  wrist, 
down  to  within  one-half  inch  of  the  fingers,  and  later- 
ally to  index  metacarpal  and  little  finger  metacarpal; 
thus  having  the  shape  of  a  truncated  cone  flattened 


RESUME  or  rk /■:(:/■:/)/. \(;  i-xrKRiMESTH  un 

oil  one  side.  I'hc  mass  appeared  In  he  i'ea(l\'  to  I)reak 
oiil  ii|)oii  the  iiliiai'  >i(le.  l)iit  none  liad  done  so.  (See 
experimental  injection  drawini;.  I'^ii;.  51.) 

Experiment  44. — Left  hand.  'I\(hni(|iie  and  results 
same  as  Kxi)erinient  43. 

Experiment  45. — Ri.uht  hand.  Cmnuhi  inserted  be- 
tween tc-ndons  of  rini;  and  little  fingers,  at  the  middle 
of  the  dorsum  of  the  hand;  entire  subapfHieunjtic  space 
hlled;  no  tendency  to  rupture  between  tendons,  but 
e\i(lence  of  beginnini;-  extension  at  two  sides  over 
index  metacarpal  and  little  finger. 

Hypotiienar  Space 

Man\-  experiments  were  made  to  determine  the 
limitations  of  this  space.  The  injections  spread  from 
the  site  of  injection  only  after  considerable  manipula- 
tion, and  then  the  mass  was  limited  to  the  hypothcnar 
area,  near  the  point  of  insertion.  The  details  of  the 
other  injections  are  omitted,  since  they  only  corroborate 
the  findings  already  noted. 

Resume  or  Preceding  Experiments  as  to  Boundaries, 

Diverticula,  and  Extensions  from  the 

Fascial  Spaces^ 

That  we  may  have  a  clear  understanding  of  the 
results    obtained    by    experimental    injection,    let    us 

'  A  study  of  the  comparative  embryology  throws  some  hght  upon  the  natural 
divisions  of  the  hand,  but  unfortunately  this  has  as  yet  only  been  worked  out 
in  relation  to  the  palmar  fascia  and  the  tendon  groups.  Dr.  McMurrich  (Am. 
Jour,  of  Anat.,  No.  2,  p.  202)  described  the  relation  of  these  in  amblystoma. 
The  muscular  masses  which  here  arise  in  the  palmar  fascia,  and  which  cor- 
respond to  the  superficial  tendons  in  the  mammalia,  divide  longitudinally  into 
three  groups,  the  lateral  parts  destined  for  the  second  and  fifth  digits,  sepa- 
rating from  the  median  parts  destined  for  the  third  and  fourth  digits.  Here  we 
see  that  thus  early  we  have  a  suggestion  of  the  ultimate  relation  of  the  parts, 
in  Dial  the  tendons  arising  from  the  palmar  fascia  leave  room  below  them 


144 


SYNOVIAL  SHEATHS  AND  FASCIAL  SPACES 


summarize  them.  The  mass  in  the  middle  palmar 
space,  in  practically  every  case,  filled  the  space  we  have 
outlined  (Fig.  52).     In  no  case  did  it  extend  into  the 

Fig.  52 


M.  P.  S. 


Photograph  of  middle  palmar  space,  tendons  being  raised, 
pencil  lies  in  its  deepest  part. 


The  end  of  the 


for  fascia]  spaces  between  them  and  the  bones.  And  again,  the  early  grouping 
of  the  tendons  corresponds  to  the  spaces,  /.  e.,  the  radial  lateral  parts  going 
to  the  index  finger,  and  being  entirely  separated  from  the  two  ulnar  parts 
corresponding  to  the  middle,  ring,  and  little  fingers.  The  most  ulnar  part 
is  not  so  distinctly  separated  from  the  median  part  as  is  the  radial,  that,  in 
a  way,  being  partly  fused  with  the  median,  but  still,  both  upon  dissection  and 
injection,  we  have  noted  a  partial  tendency  to  separation  of  the  middle  and 
ring  finger  area  from  the  little  finger  area.  How  much  the  development  of 
the  muscular  mass  of  the  hypothenar  area  may  have  to  do  with  this  is,  of 
course,  undecided,  since  we  as  yet  know  little  as  to  its  embryological  develop- 
ment, but  it  would  seem  reasonable  to  assume  that  it  has  little  relation, 
owing  to  its  extreme  ulnar  position;  so  that,  reasoning  a  posteriori,  we  would 
say  that  in  case  of  the  mammalian  embryo  there  had  been  a  persistence  of 
the  separation  between  the  index  mass  and  the  others,  while  there  had  been 
either  an  incomplete  fusion  between  the  median  and  ulnar  mass,  or  else  they 
had  partially  fused  as  development  proceeded. 


RESUME  OF  PRECEDING  EXPERIMENTS  1 45 

hypothenar  an-a  or  (o  (he  radial  side  of  the  middle 
metacarpal  bone,  excei)t  in  tiie  case  noted  where  a  band 
was  tied  about  the  wrist  in  which  the  mass  then 
iiiplui'cd  into  the  thenar  space.  In  every  case  there 
was  some  extension  along  the  lumbrical  muscles, 
almost  always  going  down  between  the  bases  of  the 
middle  and  ring  lingers,  and  sometimes  between  the 
little  and  ring  fingers,  and,  more  uncomnKjnly,  the 
middle  and  index  fingers.  Unless  great  force  was  used, 
this  was  the  limit  of  the  extension'.  When  great  force 
was  used,  the  masses  in  the  lumbrical  canals  passed 
out  into  the  loOvSe  tissue  of  the  web;  also  the  mass  filling 
the  space  proper  passed  upward  under  the  tendons 
into  the  forearm,  where  it  spread  beneath  the  deep 
muscles  nearly  up  to  the  elbow  before  it  came  to  the 
surface  at  the  lower  part  of  the  forearm  on  the  ulnar 
side.  (For  the  location  of  the  mass  in  the  forearm,  see 
Chapters  X  and  XXVI.)  In  no  case  did  the  mass  go 
through  between  the  bones  to  the  back. 

The  thenar  space  was  found  to  be  a  large  space,  but 
lying  very  deep  (Figs.  53  and  54).  It  was  not  continu- 
ous with  the  'Subcutaneous  tissue  of  the  dorsum,  and 
the  mass  was  limited  at  the  free  palmar  edge  of  the 
radial  side  of  the  palm.  The  mass  did  pass,  however, 
when  force  was  used,  into  the  perimuscular  sheath  on  the 
dorsum,  passing  proximally  and  less  frequently  distally 
to  the  adductor  transversus,  lying  between  this  muscle 
and  the  first  dorsal  interosseous.  It  also  spread  down 
along  the  lumbrical  muscle  of  the  index  finger,  making  a 
diverticulum  from  one-quarter  to  one-half  inch  long.  In 
no  case  did  it  spread  up  into  the  forearm,  even  though 
anatomical  dissection  demonstrated  that  this  would  be 
possible,  although  improbable,  and  if  it  did  it  would 
be  in  the  same  site  as  that  described  for  masses  coming 
from  the  middle  i)almar  space.  In  no  case  did  the  mass 
lie  to  the   ulnar  side  oi    the   middle   metacarpal   bone. 


146         SYNOVIAL  SHEATHS  AND  FASCIAL  SPACES 

unless  great  force  was  used  in  the  injection;  then  it 
passed  through  the  upper  part  of  the  septum  and  filled 
the  middle  palmar  space  in  one-third  of  the  cases. 

Fig.  53 


Photograph  showing  thenar  space.     The  end  of  the  pencil  appears  in  its 

deepest  part. 

Injections  into  the  hypothenar  area  showed  the  spaces 
to  be  localized  and  perimuscular  for  the  most  part, 
not  communicating  with  any  large  space,  and  hence 
of  no  particular  surgical  importance. 

Injections  of  the  subaponeurotic  space  demonstrated 
that  the  mass  would  not  rupture  through  the  aponeu- 


RESUME  OF  PRECEDING  EXPERIMENTS 


147 


rosis  unless  anatomical  exceptions  were  present.  It 
would  spread  up  to  the  wrist,  down  to  the  metacarpo- 
l)halant;eal  joint,  and  lalerall>-  to  the  edi^e  (jf  the  index 
or  little  finger  tendon  on  the  radial  and  ulnar  sides 
respectively.  W  greater  force  were  used,  it  tended  to 
spread  under  the  subcutaneous  tissues,  particularh'  on 
the  ulnar  side  and  at  the  knuckles. 


Fig.  54 


Photograph  showing  thenar  space  with  the  tendons  drawn  away  so  as 
to  expose  it  widely. 

Injections  of  the  dorsal  stibmtaneous  space  showed 
no  particular  pockets,  but  did  show  a  tendency  to 
localization  at  any  site  injected  because  of  the  obliquity 
of  fibrous  bands  crossing  from  space  to  space.  If  the 
injections  were  given  with  great  force,  the  mass  spread 
equally  in  ever^^  direction,  except  there  seemed  to  be 
some  particular  factor  at  work  limiting  in  a  certain 
measure  the  spread  of  the  mass  over  the  index  meta- 
carpal from  the  dorsum  of  the  hand  to  the  thenar  dorsal 
region,  and  vice  versa. 

Deep  injections  of  the  palm  went  into  the  spaces 
lying    underneath,    and    since    these    spaces    do    not 


148         SYNOVIAL  SHEATHS  AND  FASCIAL  SPACES 

overlap,  except  at  the  wrist,  only  one  space  is  affected 
by  a  given  punctured  wound.  It  must  be  remembered, 
however,  that  the  lymphatic  channels  from  the  centre 
of  the  palm  pass  deeply  into  the  tissue  and  come  to 
lie  immediately  adjacent  to  the  adductor  transversus, 
so  that  a  lymphatic  abscess  from  a  punctured  wound 
might  lie  in  the  thenar  area,  although  the  puncture 
might  appear  to  be  at  the  radial  side  of  the  middle 
palmar  space.  When  the  masses  spread  up  into  the 
forearm  they  appeared  under  the  flexor  profundus 
digitorum.  This  subject  is  considered  as  a  whole  in 
the  next  chapter,  devoted  to  a  study  of  the  various 
spaces  in  the  forearm. 


('hapti:r  x 

anatomy  of  the  forearm  in  relation 
to  infections 

Early  in  my  clinical  work  it  was  found  that  there 
was  little  knowledge  as  to  the  sites  of  predilection  for 
pus  in  the  forearm  when  it  extended  from  the  hand. 
Experience  showed  that  incisions  made  at  the  sites 
suggested  by  Forssell  and  others  were  followed  by  a 
tedious  convalescence  owing  to  the  necessity  of  main- 
taining satisfactory  drainage  through  the  muscular 
bodies.  A  study  of  the  forearm  after  the  same  methods 
already  pursued  in  the  hand  was  begun,  namely, 
l)y  dissection  of  serial  sections  and  injection  (jf  masses 
from  various  sites.  As  a  result  of  this,  I  changed 
entirely  the  sites  of  my  incisions,  and  had  the  great 
satisfaction  of  seeing  cases,  which  under  the  old  methods 
of  incision  required  weeks  of  constant  attention  and 
multiple  incisions,  heal  in  a  week  to  ten  days,  with 
two  or  at  most  three  incisions  made  at  one  sitting. 
Parona,  as  quoted  by  Mauclaire,  has  suggested  the 
advisability  of  one  of  these  incisions — that  upon  the 
ulnar  side  above  the  wrist. 

The  anatomical  and  experimental  data  upon  which 
these  incisions  were  based  are  detailed  in  brief  in  this 
chapter. 

ANATOMY  IN  GENERAL 

In  general  one  should  remember  that  the  s^^novial 
sheaths,  i.  e.,  the  ulnar  and  radial  bursae,  pass  under 
the  annular  ligament  and  extend  into  the  forearm  for  a 
distance  varying  from  one  to  two  inches.    The  greater 


150     ANATOMY  OF  FOREARM  IN  RELATION  TO  INFECTIONS 

part  of  the  sac  of  each  Hes  upon  the  dorsal  surface  of 
the  tendons,  i.  e.,  between  the  tendons  of  the  flexor 
profundus  digitorum  and  the  pronator  quadratus 
(Fig.  8i).  Again,  one  should  note  that  the  bloodvessels 
and  nerves  are  surrounded  by  fascial  spaces  and  when 
pus  once  reaches  them  it  can  spread  easily  along  these 
as  channels. 

Before  beginning  this  study  one  should  be  familiar 
with  the  general  anatomy  of  the  forearm;  particularly 
the  relations  of  the  flexor  carpi  ulnaris,  of  the  flexor 
profundus  digitorum  as  a  group,  of  the  flexor  sublimis 
digitorum  as  a  group,  of  the  course  of  the  median  and 
ulnar  nerves,  and  of  the  ulnar  and  radial  artery,  espe- 
cially the  former,  the  relation  of  the  pronator  quadratus 
and  the  ulna  and  radius  with  the  interosseous  mem- 
brane in  one  group  to  the  flexor  profundus  digitorum. 
With  these  general  facts  in  mind,  let  us  now  take  up 
the  study  of  the  cross-sections. 

SERIAL  CROSS-SECTIONS  OF  THE  FOREARM 

The  cadaver  arms  were  hardened  in  Kaiserling  No.  i . 
After  being  sectioned  the  pieces  were  preserved  in 
Kaiserling  No.  2.  Sections  were  made  at  the  following 
distances  from  the  radial  styloid:  3  cm.,  7  cm.,  9  cm., 
and  12  cm.  The  proximal  surfaces  of  these  sections 
were  teased  out  with  a  needle  and  forceps.  The  large 
spaces  found  were  packed  with  cotton  or  held  open  with 
small  props  and  photographs  taken  to  show  their  rela- 
tion to  the  other  structures  of  the  forearm.  One  par- 
ticularly large  free  space  was  found  in  the  lower  part  of 
the  forearm  in  direct  contiguity  with  the  tendon  sheaths 
and  in  continuity  with  the  middle  palmar  space  in  the 
hand.    It  is  upon  this  that  we  will  centre  our  attention. 

Section  i  (Fig.  55). — Three  centimeters  above  radial 
styloid.     The  space  is  rather  small  here,  opening  out 


SERLIL  CROSS  SECTIONS  01'   Till'.   roKIi.IRM  151 

from  (he  nai'row  strait  that  coiiiiccl^  it  with  the  middle 
pahiiar  s])acc  in  the  hand.  It  cxtciuU  well  across  ihc 
furcarni,  bul  is  slightly  larger  upcjii  the  radial  side. 
The  vessels  and  nerves  are  separated  from  the  space 
by  well-defined  layers  of  muscular  and  connective 
tissue.  Upon  the  superficial  surface  it  has  the  tendons 
of  the  flexor  profundus  digitorum,  covered  by  their 
synovial  sheath,  and  the  flexor  longus  pollicis,  covered 
by  its  synovial  sheath.  On  the  radial  and  ulnar  sides 
there  is  nothing  but  the  attachment  of  the  muscular 
fascial  sheath  to  the  bones,  and  the  subcutaneous 
tissue.  On  its  deep  surface  is  seen  the  pronator 
quadratus. 

Fig.  55 


UA ^  _^-y  JT^ 

iL-~:tT 

-MN 

""-n*! 

%^-- 

RA 

PQ 

IM-  -!■'■ ^-'^ 

/' 

Section  3  cm.  above  radial  styloid:  UA,  ulnar  artery;  UN,  ulnar  nerve; 
MN,  median  nerve;  RA,  radial  artery;  5,  space;  IM,  interosseous  mem- 
brane; PQ,  pronator  quadratus. 

It  is  seen  that  if  pus  ruptured  from  the  synovial 
sheaths  or  passed  upward  from  the  middle  palmar 
space,  it  would  enter  this  free  area.  It  is  manifest  that 
a  large  accumulation  could  take  place  here.  Its  most 
superficial  sites  would  be  upon  the  sides. 

Section  2  (Figs.  56  and  57). — Five  centimeters  above 
radial  styloid.  The  relation  of  the  structures  has  not 
changed  materiall}'.  The  body  of  the  pronator  quad- 
ratus is  somewhat  smaller.  The  space  here  goes  well 
to  the  ulnar  side. 


152     ANATOMY  OF  FOREARM  IN  RELATION  TO  INFECTIONS 


AU 

UN 


PQ 


Section  5  cm.  above  radial  styloid.       UA ,  ulnar  artery ;    UN,  ulnar  nerve ; 
MN,  median  nerve ;  RA,  radial  artery;  S,  space;  PQ,  pronator  quadratus. 

Fig.  57 


Drawing  ffom  teased  cross-section,  Fig.  56:  a,  extensor  secundi  internodii 
pollicis;  b,  extensor  commimis  digitorum;  c,  extensor  indicis;  d,  extensor 
minimi  digiti;  e,  extensor  carpi  ulnaris;  /,  interosseous  membrane;  g, 
ulna;  h,  pronator  quadratus;  i,  i,  flexor  carpi  ulnaris;  j,  ulnar  nerve; 
k,  ulnar  artery;  /,  flexor  profundus  digitorum;  m,  m,  flexor  sublimis 
digitorum;  n,  palmaris  longus;  0,  median  nerve;  p,  flexor  carpi  radialis; 
g,  flexor  longus  pollicis;  r,  radial  artery;  s,  space  propped  open  by  pegs 
of  wood;  t,  supinator  longus;  u,  extensor  carpi  radialis  longior;  v,  extensor 
carpi  radialis  brevior;  w,  radius;  x,  extensor  primi  internodii  pollicis. 


SERLIL  CkOSS-Si:CTJONS  OF  77/ A    FOREARM 


]5:j 


By  comparing  this  with  the?  other  sections  it  will 
be  seen  hcnv  Httlc  tissue  lies  at  the  sides,  and  it  is  at 
this  site  that  drainage  is  instituted.  The  blocks  of 
wood  holding  open  the  space  are  about  a  centimeter 
and  a  half  in  length. 

Section  3  (Fig.  58). — Seven  centimeters  above  radial 
styloid.  In  this  section  the  pronator  quadratus  has 
almost  enlirch'  disappeared.  The  space  is  bounded 
below  b}'  the  interosseous  membrane  with  the  artery 

Fig.  58 


UA 

UN 


--    MN 


Section  7  cm.  above  radial  styloid.  Pronator  quadratus  has  almost  dis- 
appeared. Notice  that  the  vessels  and  nerves  with  the  exception  of  the 
interosseous  ilA )  are  well  separated  from  the  space. 


exposed.  The  radial  and  ulnar  arteries  and  the  median 
and  ulnar  nerves  are  still  well  separated  from  the  space. 
Attention  will  be  drawn  to  this  fact  later  in  discussing 
treatment. 

Section  4  (Fig.  59). — Nine  centimeters  above  radial 
styloid.  In  this  section  the  space  is  leaving  the  inter- 
osseous membrane  and  passing  tow^ard  the  flexor  sur- 
face on  the  radial  side  of  the  deep  flexors.  It  extends 
to  the  median  nerve  and  over  to  the  ulnar  artery  and 
nerve  along  the  ulnar  side. 

This  relation  of  the  space  to  the  bloodvessels  and 
nerves  explains  why  the  injection   masses  go  up  the 


154     ANATOMY  OF  FOREARM  IN  RELATION  TO  INFECTIONS 

forearm  and  then  pass  in  a  retrograde  manner  toward 
the  hand  along  these  structures.  It  also  explains'  those 
cases  in  which  the  injection  mass  passes  up  along 
the  median  above  the  elbow.  It  helps  to  explain  the 
trophic  sequelae  and  cases  of  ulcerative  hemorrhage 
that  have  been  reported.    In  the  upper  part  of  the  fore- 

FiG.  59 


S 

MN 

RA 


lA 


Section  9  cm.  above  radial  styloid.     Note  the  relation  of  the  space  to  the 
median  nerve  and  the  ulnar  artery:  lA,  interosseous  artery. 

arm  the  space  follows  the  nerves  and  bloodvessels  and 
becomes  indefinite.  It  is  seen  that  the  ulnar  nerve 
and  artery  along  which  the  secondary  mass  extends 
lie  immediately  under  the  junction  of  the  flexor  carpi 
ulnaris  with  the  flexor  profundus  digitorum.  This  indi- 
cates then  a  second  site  for  incision  (Figs,  iii  and  112). 

EXPERIMENTAL  INJECTIONS  OF  THE  FASCIAL  SPACES  OF 
THE  FOREARM 

To  verify  the  findings  here,  experimental  injections 
were  made  with  plaster  of  Paris  from  various  sites 
that  might  be  the  origin  of  spreading  abscesses.  These 
will  show  the  intimate  relation  which  exists  between 
the  fascial  spaces  of  the  hand  and  the  forearm  and  those 
about  the  bloodvessels. 

It  should  be  remembered  that  we  are  only  selecting 
illustrative  experiments  which  bear  upon  the  subject 


INJECTION  OF  THE  R.IDLIE  BURSA  loo 

ill  hand,  and  thai  thcN'  do  not  !>>  any  means  n-jji-cscnt 
a  foniplctc  ix'pcjrt  oi  the  rtsuhs  obtained  from  injec- 
tions at  these  various  sites. 

Injection  of  the  Radial  Bursa 

Out  of  the  eight  injections  made  into  the  radial 
bursa  under  high  pressure  to  produce  rupture  and 
extravasation  of  the  mass,  six  showed  extension  from 
a  rui)ture  at  the  i)roximal  end  into  the  forearm  (see 
p.  125).  The  following  may  be  taken  as  an  example  of 
the  condition  found  upon  dissection  of  the  arm. 

Experiment  46. — Injection  under  great  pressure  of 
synovial  sheath  of  flexor  longus  pollicis  by  plaster  of 
Paris. 

Upon  dissection,  the  mass  was  found  to  have  filled 
the  synovial  sheath  completely  and  ruptured  from  the 
proximal  end  into  the  tissue  of  the  forearm.  No  ex- 
tension has  taken  place  into  the  hand  either  by  rup- 
ture of  the  sheath  in  continuity  or  by  retrograde  move- 
ment from  the  forearm  under  the  annular  ligament, 
although  the  mass  had  extended  down  to  the  annular 
ligament  and  lay  under  the  superior  border.  The 
attachment  of  the  flexor  longus  pollicis  to  the  bone 
w^as  partially  destroyed,  owing  possibly  to  the  friability 
of  the  muscle  in  this  particular  cadaver,  but  the  mass 
showed  a  tendency  to  follow  this  muscle  and  a  pre- 
dilection for  the  radial  side  of  the  forearm.  A  portion 
of  the  mass  lay  between  the  flexor  longus  pollicis  and 
the  flexor  sublimis  digitorum.  The  larger  part,  how- 
ever, extended  underneath  the  flexor  profundus  digi- 
torum to  fill  a  space  bounded  on  the  ulnar  side  by  the 
flexor  carpi  ulnaris,  on  the  radial  side  by  the  flexor 
longus  pollicis,  dorsally  by  the  bones  with  the  inter- 
osseous membrane  and  pronator  quadratus.  This  ex- 
tended up  to  within  three  inches  of  the  elbow-joint 
and  distally  to  the  wrist-joint.     A  great  amount  of 


156     ANATOMY  OF  FOREARM  IN  RELATION  TO  INFECTIONS 

material  was  present.  The  area  filled  was  practically 
that  described  in  the  cross-sections,  except  that  the 
mass  did  not  extend  between  the  flexor  carpi  ulnaris 
and  thej^flexor  profundus. 

Fig.  6o 


X-ray  Plate. — Injection  via  tendon  sheaths  of  both  thenar  and  middle 
palmar  spaces  with  considerable  force.  Note  extension  into  forearm  from 
middle  palmar  space.  Showing  where  pus  would  lie  in  neglected  cases,  as 
in  Cases  25  and  45. 

Injection  of  the  Ulnar  Bursa 

Injection  of  the  ulnar  bursa  resulted  frequently  in 
rupture   at   the   proximal   end.     The   mass  showed   a 


INJECTIONS  FROM   Till:   M I I)-I'.ILMAR  SPACE       157 

greater  predilection  for  the  ulnar  side,  and  had  a  ten- 
dency to  return  along  the  course  of  the  ulnar  artery. 
This  extension  along  the  vessel  explains  the  presence 
of  the  iilccratioi]  of  the  vessel  and  profuse  hemorrhage 
which  occurs  al  times. 

Experiminit  47. — Injection  of  the  ulnar  bursa,  rup- 
ture from  proximal  end,  filling  deep  space  in  the  fore- 
arm (F'ig.  39). 

The  ulnar  bursa  was  injected  with  great  force. 
Rui)ture  occurred  at  the  proximal  end;  the  mass  was 
found  to  fill  space  described  above,  being  dorsal  to  the 
fiexor  profundus  tendons  and  muscles.  It  showed  a 
primary  ]:)redilection  for  the  ulnar  side,  but  returned 
along  both  the  ulnar  and  radial  vessels.  There  was 
also  an  extension  along  the  median  nerve,  this  tongue 
of  plaster  following  the  nerve  to  two  inches  proximal 
to  the  elbow-joint. 

Injections  from  the  Mid-palmar  Space 

What  is  the  result  when  the  mass  extends  from  the 
mid-palmar  space  of  the  hand  ? 

Experiment  48. — (Fig.  60.)  In  this  case  the  result 
is  shown  by  an  ;v-ray  picture.  Both  the  thenar  and 
middle  palmar  spaces  w^re  injected  with  force  from  the 
index  and  ring  fingers  respectively.  The  thenar  mass 
remained  in  its  usual  compartment,  while  the  middle 
palmar  mass  passed  up  under  the  group  of  flexor  ten- 
dons into  the  forearm.  Note  the  prolongations  along 
the  lumbrical  muscles,  and  the  thinness  of  the  mass 
under  the  site  of  the  annular  ligament. 

This  graphically  represents  what  has  been  suggested 
in  the  preceding  pages,  that  extension  to  the  forearm 
may  occur  from  middle  palmar  space  infections,  but 
is  not  likely  to  from  the  thenar  space. 

This  tendency  for  pus  to  extend  along  the  vessels 


158     ANATOMY  OF  FOREARM  IN  RELATION  TO  INFECTIONS 

and  nerves  helps  to  explain  the  frequency  of  trophic 
changes  which  so  often  occur  as.  a  sequence  of  infections 
of  the  hand. 

Experiment  49. — Injection  with  great  force  through 
synovial  sheath  of  the  ring  finger,  filling  mid-palmar 
space  and  extending  under  anterior  annular  ligament 
into  forearm.  (See  experimental  injection  drawing, 
Fig.  61.) 

Fig.  61 


Schematic  drawing  made  from  a  dissection  of  a  hand  in  which  the  injec- 
tion was  made  along  the  tendon  sheath  of  the  ring  finger.  The  mass  filled 
the  middle  palmar  space  and  extended  along  two  of  the  lumbrical  muscles 
and  under  the  annular  ligament  into  the  forearm. 


The  mass  was  injected  with  considerable  force.  The 
middle  palmar  space  as  described  was  filled.  Thenar 
and  hypothenar  areas  free,  mass  along  little  and  ring 
finger  lumbricals  for  three-fourths  inch,  none  along 
other  fingers,  none  through  between  bones  to  back, 
mass  extended  under  tendons  strictly,  up  into  forearm, 


FINDINGS  BY  DISSECTION  AND  INJECTIONS        159 

where  a  large  mass  was  found  l>'ing  under  the  deep 
muscles  u|)(;n  the  prc>nat(jr  f|uadratus  and  interosseous 
septum.  It  extended  into  the  intermuscular  fascial 
spaces  \\\)  to  the  ])ronator  radii  teres,  it  came  to  the 
surface  late  u|)()n  the  radial  side  at  about  two  inches 
above  wrist,  but  the  mass  was  most  marked  upon  the 
ulnar  side  from  above  downward  between  the  flexor 
carpi  ulnaris  and  the  dee[)  tendons  and  muscles,  so 
that  this  upper  mass  was  most  easily  reached  by  sepa- 
rating^ the  flexor  carpi  ulnaris  alone:  its  volar  edge 
from  the  adjacent  muscular  body.  This  also  exposed 
the  ulnar  artery  and  nerve  which  were  surrounded  by 
the  mass. 

This  is  further  exemplified  by  an  x-ray  picture  taken 
of  an  arm  injected  as  shown  by  the  legend  (Fig.  6i), 
the  mass  being  impregnated  w4th  red  lead. 


RESUME  OF  FIXDIXGS  BY  DISSECTION'  AXD  EXPERIMENTAL 

IXJECTIOXS 

By  these  experiments  we  have  demonstrated  that  in 
neglected  cases,  no  matter  whether  the  pus  extends  up 
from  the  ulnar  bursa,  radial  bursa,  or  the  mid-palmar 
space,  the  same  area  of  the  forearm  is  involved,  thus 
indicating  the  position  pus  would  occupy  in  neglected 
cases,  or  in  those  cases  in  which  early  rupture  of  the 
synovial  sheaths  (ulnar  and  radial  bursa)  occurs.  This 
space  lies  under  the  flexor  profundus  digitorum  ten- 
dons and  muscle  (Fig.  62).  About  three  inches  up  on 
the  forearm  the  pus  begins  to  invade  the  intermuscular 
septa,  passing  first  to  the  area  about  the  median  nerve, 
and  later  to  the  area  about  the  ulnar  artery  and  nerve. 
Here  it  lies  between  the  flexor  carpi  ulnaris  and  the 
flexor  profundus  (Fig.  63).  This  is  about  four  inches 
u\)  on  the  forearm.  From  here  it  may  pass  toward 
the  elbow  along  the  vessels  and  nerves,   particularly 


160     ANATOMY  OF  FOREARM  IN  RELATION  TO  INFECTIONS 

the  median  nerve,  or,  more  commonly,  it  may  extend 
distally  along  the  ulnar  artery  under  the  flexor  carpi 
ulnaris,  and  appear  subcutaneously  about  three  inches 

Fig.  62 


Photograph  of  cross-section,  7  cm.  below  the  radial  styloid,  showing  area 

filled  with  pus. 


Fig.  63 

.'■■■'■y 

i] 

UA-^-M 

W^ 

m 

UN — ..^m." 

It 

W 

^^.^«^™m« 

1 

1 

\ 

Photograph  of  forearm 'just  below  the  middle,  showing  position  of  pus 
in  its  relation  to  the  ulnar  artery  and  nerve  and  the  median  nerve. 

Up  on  the  ulnar  side.  It  may  extend  downward  along 
the  radial  artery,  but  this  is  certainly  an  uncommon 
termination.     The  larger  part  of  the  space  is  about 


FINDfNCS   HY  DISSECT  ION  .INI)  INJECTIONS         101 

two  inches  above  the  wiisl.  Its  most  siipcrlicial  parts 
are  on  either  side,  just  volar  to  the  ulna  and  radius. 
The  floor  of  the  sj^ace  is  made  up  by  the  pronator 
quadratus  at  the  wrist  and  the  interosseous  septum 
above.  The  si)ace  nia\-  hold  a  half  pint  ov  more  of 
fluid. 

The  only  other  distinctly  separated  space  is  that 
comprising  the  subcutaneous  tissue. 

(For  the  surgical  application  of  these  facts  see 
Chapters  XXVI  and  XXVII.) 


II 


SECTION   II 

THE  SURGICAL  CONSIDERATION  OF  TENDON- 
SHEATH   INFECTIONS   AND   FASCIAL 
SPACE  ABSCESSES   OF  THE 
HAND  AND  FOREARM 


CHAPTER   XI 

PATHOGENESIS— SOURCE  OF  INVOLVEMENT 

OF  THE  TENDON  SHEATHS  AND 

FASCIAL  SPACES 

Concerning  the  surgical  application  of  the  anatomi- 
cal and  experimental  data  we  have  discussed  in  the 
previous  chapters,  it  should  be  borne  in  mind  that  our 
remarks  are  strictly  confined  to  a  discussion  of  these 
facts  in  relation  to  the  subject  of  tendon  sheath  and 
fascial  abscesses  in  the  hand.  Lymphatic  infection 
will  be  considered  only  in  so  far  as  it  has  a  distinct 
bearing  upon  these  conditions,  a  full  discussion  being 
reserved  for  a  subsequent  chapter. 

ETIOLOGY  IN  GENERAL 

In  all  of  the  cases  coming  under  observation,  the 
accumulations  of  pus  have  been  submitted  to  bacterio- 
logical examination,  and  the  results  differed  in  nowise 
from  the  findings  elsewhere;  nearly  all  the  slow  growing 
abscesses  showing  the  staphylococcus  in  pure  culture, 
while  those  originating  in  the  tendon  sheaths,  if  of  a 
fulminating   nature,   showed   the   streptococcus   unless 


164  PATHOGENESIS    ■ 

there  was  a  secondary  infection.  The  severity  of  the 
course  was  often  in  inverse  relation  to  the  extent  of 
the  primary  wounds.  Again,  the  general  health  and 
resistance  of  the  patient  were  often  below  normal. 
The  latter  factor  has  been  particularly  conspicuous. 
On  the  other  hand,  cases  of  localized  infection  (from 
deep  lacerated  wounds)  have  followed  in  very  robust 
individuals,  where  doubtless  the  infection  has  been 
carried  directly  to  the  space  infected.  Again,  it  has 
been  noted  that  local  trauma,  without  apparent 
abrasion  of  the  skin,  has  acted  by  lessening  the  local 
resistance,  hence  favoring  infection.  We  soon  learned 
alsp  that  the  older  the  patient  the  greater  would  be 
the  danger  of  a  serious  course  and  complications.  The 
gonococcus  may  be  found  in  some  cases,  almost  always 
of  hematogenous  origin. 

SOURCE  OF  INVOLVEMENT  OF  THE  VARIOUS  SHEATHS 

Attention  has  been  drawn  above  to  the  theories 
advanced  by  the  earlier  authors  as  to  the  source  of 
infection  of  the  sheaths.  It  is  probable  that  they  may 
be  involved  either  by  lymphatic  extension  or  direct 
continuity.  The  latter,  of  course,  needs  no  discussion. 
That  wounds  involving  the  sheath  may  be  an  atrium 
and  that  abscesses  lying  in  continuity  may  cause 
necrosis  and  involvement  will  be  admitted  by  all. 
It  is  rather  uncommon  for  a  felon  to  give  rise  to 
tenosynovitis.  The  same  may  be  said  of  suppurative 
arthritis  of  the  distal  interphalangeal  joint,  and  the 
metacarpophalangeal  joint.  This  is  explained  by  the 
anatomical  relations,  which  also  probably  explain 
the  frequent  involvement  from  the  proximal  inter- 
phalangeal joint  (see  pp.  102  and  103).  I  have  seen 
extension  to  a  sheath  from  abscesses  in  a  lumbrical 
canal.     Here,   however,   the  involvement  is  likely  to 


EXTENSION  FROM  ONE  S UK, IT II   TO    INOTIIKR       ](;5 

\)v  localizfd  lo  llic  |)r()\inial  cml  ol  the  liiit;fr  slifallis. 
Indeed,  this  holds  true  for  all  of  these  cases  which 
(le\-elop  as  a  result  of  abscesses  in  contiiuiit}.  One 
explanation  of  this  can  be  found  in  the  fact  that  the 
contii^uous  inflammation  has  pnjbably  i^i\en  rise  to 
plastic  adhesions  in  the  sheath  before  the  actual  in- 
volvement has  taken  place,  and,  again,  these  l(;cal 
accumulations  have  generally  been  produced  1)\'  the 
staphylococcus  or  some  like  germ  of  moderate  viru- 
lence. This  is  also  true  of  involvement  of  the  ulnar 
or  radial  sheaths  secondary  to  abscesses  in  the  j^alm, 
as  was  exemplified  by  the  case  of  Henderson  (see 
Case  XVI). 

The  question  of  lymjjhatic  involvement  is  one  that 
is  not  so  easily  demonstrable,  but  any  surgeon  can 
recall  numerous  histories  of  patients  who  developed  an 
infection  of  a  sheath  within  twent>'-four  to  thirt\'-six 
hours  after  a  simple  needle  prick  of  a  finger  upon  the 
volar  surface.  This  is  most  commonly  met  with  in 
the  distal  or  middle  phalanx  (see  Case  XI),  and  is 
almost  always  streptococcic  in  origin.  Why  it  does 
not  occur  in  dorsal  wounds  is  understood  when  we 
remember  that  the  course  of  the  lymphatic  vessels  is 
from  the  palmar  to  the  dorsal  surface.  It  is  this  type 
of  infection  which  presages  the  most  disastrous  results, 
since  localization  to  any  part  of  the  sheath  is  tin- 
common,  and  unless  early  incision  is  instituted,  necrosis 
of  the  sheath  takes  place  with  serious  local  and  con- 
stitutional sequelae.  The  possibility  of  gonococcic 
tenosynovitis  of  hematogenous  origin  must  always  be 
borne  in  mind  in  cases  with  an  obscure  origin.  Two 
such  cases  have  come  under  my  observation. 

EXTENSION  FROM  ONE  SHEATH  TO  ANOTHER 

The  extension  from  one  sheath  to  another  follows 
strictly  on  anatomical  lines.     Apparent  exception   to 


166  PATHOGENESIS 

this  is  found  in  simultaneous  involvement  of  the  thumb 
and  ulnar  bursa  without  involvement  of  the  radial 
bursa,  the  thumb  being  primary,  as  was  found  in  four 
of  Forssell's  cases.  He  did  not  note  any  cases  of  little 
finger  infection  and  radial  bursitis  without  associated 
ulnar  bursitis.  Before  this  exception  is  admitted  further 
observations  must  be  made.  In  two  of  my  cases  I  was 
led  to  the  same  conclusion  on  first  opening  the  sheath 
of  the  flexor  longus  pollicis,  but  further  search  revealed 
pus  at  both  ends  of  the  sheath. 

The  anatomical  relations  of  the  finger  sheaths  of 
the  little  finger  and  thumb  to  the  ulnar  and  radial 
bursse  respectively,  as  well  as  the  intercommunication 
of  these  latter,  have  already  been  discussed  (see  pp. 
105  and  109).  When  we  are  dealing  with  an  infection 
of  little  virulence,  such  as  one  due  to  the  staphylococ- 
cus, we  frequently  find  a  plastic  exudate  or  adhesions 
closing  the  narrowed  opening  between  these  parts  and 
the  infection  located  in  any  section;  as  for  instance, 
the  finger  sheath,  ulnar  bursa,  radial  bursa,  or  the 
intermediary  sheaths  at  the  wrist.  Indeed,  I  have 
at  times  seen  an  infection  of  an  ulnar  bursa  limited 
to  that  part  of  the  sheath  between  the  base  of  the  finger 
and  the  annular  ligament,  the  part  of  the  sheath  in  the 
forearm  being  uninvolved,  protected  by  adhesions  at 
the  annular  ligament.  My  experience  here  agrees  with 
the  earlier  observations  of  Schwartz  and  Gosselin, 
and  differs  from  that  of  Forssell,  who  says  that  "out 
of  34  cases  of  ulnar  bursitis,  an  extension  of  the  infec- 
tion to  the  tendon  sheath  of  the  little  finger  was  found 
in  30  cases  on  their  entrance  into  the  hospital,  and  if 
we  assume  with  Poirier  that  the  ulnar  bursa  is  com- 
pletely separated  in  33  per  cent,  of  the  cases,  it  is  very 
improbable  that  a  secondary  boundary  should  in  a 
single  one  of  the  aforementioned  cases  have  developed 
through  an  adhesive  inflammation.     ...      I   have 


EXTENSION  FROM  OXE  SIIE.ITII   TO  .1  SOT  HER        107 

never,  in  opei'aliii.i;  upon  a  siipi)iii-a(i\c  hiirsitis,  fouiul 
williiii  llie  l)iii'sa  i)r()i)er  a  (il)iiii()iis  or  i)laslic  synovitis 
in  such  a  mass  as  to  notal^ly  affect  the  operation." 

In  general,  however,  it  may  be  said  that  in  the 
virulent  types  of  infection  beginning  in  the  little  finger 
sheath,  we  will  almost  always  have  an  involvement  of 
the  ulnar  bursa  and  in  a  majority  of  cases  the  radial 
bursa  and  sheath  of  the  flexor  longus  pollicis  will  be 
involved  from  this  (see  p.  109).  The  converse  is  also 
true. 

Besides  spreading  by  direct  continuity  these  infec- 
tions may,  of  course,  involve  one  or  more  sheaths 
secondarily  by  a  rupture  from  a  previously  infected 
sheath. 

I  report  the  case  of  Mr.  P.,  who  had  an  infection  of 
the  middle  finger  tendon  sheath  which  extended  by 
way  of  the  lumbrical  canal  over  to  the  tendon  sheath 
of  the  ring  finger,  since  it  demonstrates  the  possibility 
of  such  infection  spreading  to  contiguous  tendon 
sheaths,  a  point  that  has  not  been  brought  out  in 
previous  contributions. 

Case  VII.— Mr.  P.,  referred  by  Dr.  A.  T.  Horn. 

History:  Patient  received  slight  lacerated  wound  on 
the  flexor  surface  of  the  middle  finger.  Inside  of  two 
days  the  finger  was  markedly  swollen  and  tender,  and 
when  seen  in  consultation  on  the  third  day  tenderness 
was  marked  throughout  the  course  of  the  tendon 
sheath,  the  finger  was  flexed  and  on  extension  presented 
the  greatest  amount  of  pain  at  the  proximal  end  of  the 
sheath. 

A  diagnosis  of  tenosynovitis  was  made  and  the 
tendon  incised  throughout  its  length.  The  lumbrical 
spaces  on  either  side  were  involved  and  were  drained. 
The  infection  apparently  subsided,  but  on  the  seventh 
day  it  was  noted  that  the  ring  finger  was  markedly 
flexed,  tender  throughout  the  course  of  the  sheath,  and 


168  PATHOGENESIS 

that  on  extension  pain  was  present  at  its  proximal  end. 
The  diagnosis  of  infection  of  this  sheath  due  to  con- 
tiguity of  the  lumbrical  space  was  made,  and  the  tendon 
sheath  was  incised  and  drained  by  an  incision  upon 
its  flexor  surface.  From  this  time  on  there  was  an 
uninterrupted  recovery  as  to  the  infection,  but  the 
ultimate  result  showed  the  patient  with  moderate 
flexion  of  the  ring  finger  at  its  proximal  interpha- 
langeal  joint,  no  motion  at  its  distal  joint,  and  complete 
motion  at  the  metacarpal  phalangeal  joint.  The  middle 
finger  was  held  semiflexed  with  complete  flexion  at 
the  metacarpal  phalangeal  joint;  other  joints  of  the 
finger  could  not  be  moved. 

The  extension  from  the  sheaths  by  rupture  has  been 
discussed  in  the  chapter  on  experimental  injections 
(Chapter  IX),  and  will  be  considered  in  the  subsequent 
section  upon  the  course  of  involvement  of  the  fascial 
spaces. 

SOURCE  OF  INVOLVEMENT  OF  THE  IMPORTANT  FASCIAL 
SPACES   IN   THE  HAND.     GENERAL   DISCUSSION 

Involvement  from  the  Tendon  Sheaths. — This 
source  is  certainly  one  of  the  most  common,  and  the 
experimental  and  anatomical  discussions  in  Chapters 
VII,  VIII,  and  IX  had  for  one  of  their  purposes  the 
determination  of  these  facts.  Accepting  the  results 
of  these  investigations  as  probabilities  only,  I  have 
been  able  to  verify  nearly  every  statement  by  clinical 
observation.  In  the  less  virulent  cases  inflammatory 
barriers  may  be  thrown  out  that  will  close  the  normal 
anatomical  canals.  If  the  process  continues  any  time, 
however,  or  the  process  is  acute,  the  result  follows 
absolutely  along  anatomical  lines. 

The  middle  palmar  space  becomes  involved  second- 
arily to  a  tendon  sheath  infection  of  the  middle,  ring, 


INI'OIJ'EMKNT  OF  F.ISCI.IL  SPACES  IN  TJIK  11,1  \  I)     HlO 

and  little  liMLici'.  Al  times  the  middle  liiii;ei'  ma\  rii|)- 
tiire  into  the  liimhrieal  space  i)et\\('en  the  index  and 
middle  linger,  and  by  secondary  rui)ture  may  involve 
the  thenar  spaces.  But  even  in  cases  of  such  a  lumbri- 
cal  rupture,  it  generally  involves  the  middle  palmar 
space. 

The  tJiciKW  space  is  involved  as  a  result  of  rupture 
from  the  tendon  sheath  of  the  index  finger  and  excej)- 
tionally  from  the  middle  finger.  It  also  occurs  at 
times  that  a  rupture  of  the  flexor  longus  pollicis  sheath 
may  involve  this  space,  but  here  the  pus  is  more 
likely  to  come  to  the  surface  at  the  web. 

The  lumhrical  spaces  are  most  commonly  the  site 
of  the  primary  focus  after  rupture  from  the  proximal 
end  of  the  various  sheaths.  The  middle  and  ring 
fingers  may  rupture  on  either  or  both  sides.  The  index 
finger  most  commonly  ruptures  to  the  ulnar  side,  but 
may  rupture  upon  the  radial  side,  while  the  little 
finger  sheath  ruptures  only  upon  its  radial  side. 

Infection  of  the  dorsal  tendon  sheaths  is  so  uncom- 
mon that  prognostic  data  here  would  not  be  of  an}' 
value. 

Direct  Implantation  of  the  Infection  in  the 
Spaces. — The  middle  palmar  space  is  more  often  in- 
fected by  implantation,  both  through  direct  puncture 
and  extensive  crushing  injuries  and  lacerated  wounds. 

Case  VIII. — Crushing  injury  of  hand;  fracture  of 
ring  finger  metacarpal,  with  infection  involving  the 
middle  palmar  space. 

Mr.  B.  P.,  aged  twenty-five  years,  Chicago  Charity 
Hospital. 

Patient's  Statement:  Patient  states  that  he  was 
thrown  in  front  of  a  moving  car  and  the  wheel  ran  on 
his  hand,  but  evidently  did  not  cross  it.  Condition 
found  upon  entrance  to  hospital  following  day:  Lacer- 
ated wounds  across  dorsum  of  right   hand,   midwa>', 


170  PATHOGENESIS 

two  and  one-half  inches  long,  rather  deep,  into  sub- 
cutaneous tissue;  lacerated  wound  of  palmar  surface 
two  inches  long  and  irregular,  so  that  there  was  a  flap 
raised  up  consisting  of  tissue  superficial  to  palmar 
aponeurosis;  wounds  infected;  fracture  of  metacarpal 
of  middle  finger;  tendons  intact;  fingers  extended; 
not  particularly  tender  to  flexion  and  extension, 
although  thumb  was  more  tender  than  others.  (This 
was  later  found  to  be  due  to  a  fracture  of  the  proximal 
phalanx.)  Whole  hand  swollen,  no  particular  areas. 
Flaps  opened  to  allow  drainage.  Hot  boric  dressings 
applied. 

Patient's  temperature  and  pulse  demonstrated  a 
continuation  of  the  severe  infection,  and  two  weeks 
after  entrance,  owing  to  the  site  of  the  injury  and  the 
greater  rigidity  of  the  middle,  ring,  and  little  fingers,  a 
diagnosis  of  pus  in  the  middle  palmar  space  was  made. 
Proximal  phalanx  extended,  two  distal  phalanges  flexed 
45  degrees  from  the  same  line.  Incision  into  middle 
palmar  space  disclosed  abscess  there  in  communication 
with  the  fractured  metacarpal.  Through-and-through 
drainage  from  palm  to  dorsum  instituted.  Rapid  fall 
of  temperature  and  pulse  followed.  Drainage  was  free. 
Edema  and  swelling  continued  for  some  time,  beginning 
to  decrease,  however,  at  the  end  of  the  first  week. 

January  29  (second  day).  Temperature  101.5°  to 
102^°;  pulse,  70  to  104. 

January  30.  Temperature,  101°  to  103.25°;  pulse, 
80  to  108. 

February  i.  Temperature,  101.5°  to  101-25°;  pulse, 
100  to  108. 

February  3.  Temperature,  99°  to  99i°;  pulse,  92 
to  104. 

February  4.  Temperature,  98^°  to  99.5°;  pulse,  80 
to  92. 

February  6.  Temperature,  99.5°  to  102.5°;  pulse, 
88  to  92. 


INVOLVEMENT  OF  FASCIAL  SPACES  IN  77/ F  HAM)     171 

I  IcM'c  the  iiilcctioii  ex  idciit  ly  cxtciulcd. 

February  9.  'I'cinixrat  lire,  100.5°  to  FOlg^;  pulse, 
84  to  90. 

Ft'l)riiar\-  t  i.  Temperature,  99.25°  to  104^°;  pulse,  X4 
to  92. 

February  13.  Temperature,  100°  to  103.25°;  pulse, 
96  to  124. 

February-  15.  Temperature,  100.25°  to  ioi-^°;  pulse, 
76  to  90. 

Operation:  Middle  palmar  space  drained. 

February  17.  Temperature,  99.25°  to  100.5°;  pulse, 
96  to  100. 

Temperature  curve  begins  to  fall  and  septic  symp- 
toms decrease.    Sleeps  well  and  begins  to  cat. 

February  19.  Temperature,  99.5°  to  101.25°;  pulse, 
92  to  96. 

February  22.  Temperature,  99^°  to  101°;  pulse, 
94  to  96. 

Drain  removed. 

Gradual  fall  until  March  3,  when  the  temperature 
fell  to  normal  and  remained  there. 

March  20.  Temperature  and  pulse  normal;  hand 
still  swollen  and  little  movement  in  fingers;  position 
of  digits  same  as  upon  entrance;  can  move  all  slightly 
without  pain,  index  most  of  all;  thumb  slightly  tender 
to  passive  movements  (fractured).  Other  fingers: 
little  pain  produced  by  manipulation. 

April  20.  Hand  improved  much;  much  greater  range 
of  movement  of  fingers;  evident  that  nearly  full 
functions  will  be  restored. 

In  deciding,  however,  whether  or  not  the  middle 
palmar  space  has  been  invaded  by  injury,  it  is  well  to 
bear  in  mind  that  the  space  lies  dorsal  to  the  tendons  and 
superficial  vessels;  hence  these  can  be  uncovered  by  a 
lacerated  wound,  and  the  space  not  neccssarih-  become 


172  PATHOGENESIS 

involved,  although  it  is  probably  true  that  unless 
scrupulous  care  be  taken  to  give  perfect  drainage 
superficially,  the  space  will  later  become  involved, 
since  the  fascial  sheet  separating  the  tendons  from  the 
space  is  very  thin,  as  has  already  been  pointed  out. 
This  same  fact  is  to  be  remembered  in  case  of  a 
punctured  wound,  since  while  the  loose  cellular  tissue 
surrounding  the  tendons,  superficial  vessels,  and  the 
lumbrical  muscles  would  harbor  pus  for  a  short  time, 
which,  if  properly  drained,  need  not  extend  to  the  space, 
yet  if  intervention  is  withheld  for  any  length  of  time  it 
must  extend  either  down  along  the  lumbrical  muscles, 
through  the  fibrous  canal  at  the  distal  part  of  the  palm 
already  noted,  and  thence  into  the  cellular  tissue  dor- 
sal to  the  web,  or  break  into  the  palmar  space,  and  in 
nearly  every  case  the  latter  result  will  be  found  to 
have  occurred  long  before  the  former. 

Owing  to  the  juxtaposition  of  the  metacarpal  bones, 
particularly  of  the  middle  and  ring  fingers,  any  crush- 
ing injury  of  the  hand,  with  consequent  compound 
fracture  of  these  bones,  will  frequently  lead  to  infec- 
tion through  this  dorsal  wound,  as  I  myself  have  seen 
(Case  VIII).  The  metacarpal  bone  of  the  little  finger, 
being  somewhat  distant  from  the  space,  is  not  so  likely 
to  open  the  space,  while  the  metacarpal  bone  of  the 
index  finger  (and  in  exceptional  conditions  the  middle 
finger)  will  open  the  thenar  space.  Compound  frac- 
ture of  the  thumb  metacarpal  would  more  likely  lead 
to  dorsal  subcutaneous  accumulations  of  pus,  or  even 
synovial  infection  of  the  sheath  of  the  flexor  longus 
pollicis,  than  thenar  space  infection.  It  is  well  to  bear 
these  predisposing  etiological  factors  in  mind  when  we 
come  to  discuss  the  diagnosis  of  the  position  of  the 
pus. 

Since  few  lymphatics  lead  into  the  hypothenar  space, 
and    it   is   isolated    from    adjacent    areas   by    densely 


INVOLVEMENT  OF  FASCIAL  SPACES  IN  THE  HAND     173 

circumscriht'd  lissuc,  infection  here  is  due  most  often 
to  direct  inii)lantation.  For  instance,  a  palmar  in- 
fection will  riii)tiire  into  the  ulnar  bursa  or  extend, 
in  preference,  under  the  annular  ligament,  and  then 
rupture  into  the  cellular  spaces  of  the  forearm,  before 
it  will  overcome  the  resistant  tissue  intervening  be- 
tween it  and  the  hypothenar  space  (see  Cross-sections, 
Figs.  24  and  25).  The  space  can  be  infected,  however, 
from  the  dorsum,  through  a  compound  fracture  of 
the  fifth  metacarpal,  but  even  there  the  pus  would 
be  more  likely  to  accumulate  upon  the  dorsum,  owing 
to  the  intimate  relation  of  the  hypothenar  muscles  to 
the  bone,  than  in  the  space,  unless  the  injury  of  the 
muscles  is  extensive. 

Direct  infection  of  the  subaponeurotic  space  can  occur 
by  punctured  or  incised  wounds,  or  by  crushing  in- 
juries compounded  particularly  upon  the  dorsum.  The 
incised  wounds,  lying  transverse  to  the  tendons,  would 
be  less  likely  to  lead  to  subaponeurotic  accumulations 
of  pus,  owing  to  the  retraction  of  the  aponeurosis  by 
the  extensor  muscles,  thus  opening  the  gap  widel}- 
so  that  free  drainage  would  ensue  into  the  subcutaneous 
tissue,  or  externally.  Longitudinal  cuts,  on  the  con- 
trary, would  tend  to  close,  and  thus  prevent  free 
drainage. 

The  suhciitajieoiis  tissue  is  infected  in  the  same  man- 
ner. It  also  can  be  invaded  in  the  pileous  infections 
occurring  upon  the  dorsum,  which  at  times  become 
carbuncular  in  their  nature,  thus  extending  from  the 
skin  proper  into  the  subcutaneous  tissue. 

Involvement  by  Lymphatic  Extension. — Besides 
the  direct  infection  of  these  spaces,  they  may  become 
involved  by  an  extension  from  adjacent  injuries,  either 
through  the  lymphatics,  or  b}'  continuity  of  fascial 
spaces.  There  is  abundant  clinical  prool  that  infection 
by  the  less  \iruU'nt   germs  can   sj)read   1)\    Kniphatic 


174  PATHOGENESIS 

channels,  and  abscesses  develop  at  distant  spots.  Upon 
the  other  hand,  it  is  often  impossible  to  say  whether 
an  extension  has  occurred  by  means  of  the  lymphatic 
vessels,  or  by  means  of  the  spaces,  and  fortunately  in 
these  cases  it  is  not  necessary  to  decide  the  question, 
since  the  two  courses  are  generally  side  by  side.  Thus, 
the  deep  lymphatics  pass  from  the  fingers  along  with 
the  vessels  in  the  same  space  in  which  the  lumbrical 
muscle  lies,  and  in  a  given  case,  for  instance,  an  infec- 
tion at  the  base  of  the  ring  finger  which  spreads  into 
the  middle  palmar  space,  who  can  say  whether  it 
extends  by  means  of  the  lymph  vessel  or  along  the 
lumbrical  muscle,  going  to  the  radial  side  of  that 
finger?  Moreover,  we  do  not  need  to  know.  What  is 
of  importance  is  to  know  where  the  pus  lies  after  it 
has  extended,  and  certainly  a  study  of  the  course  of 
the  lymphatic  channels  is  of  importance  in  relation 
to  this.  It  is  not  our  purpose  to  discuss  the  subject 
of  lymphatic  infection  as  a  whole,  nor  do  more  than 
draw  attention  to  the  monumental  work  of  Sappey, 
Leaf,  Malgaine  and  others,  by  which  we  can,  in  some 
measure,  prognosticate  the  position  of  a  metastatic 
abscess  when  the  point  of  primary  infection  is  known. 
The  subject  as  a  whole  will  be  discussed  in  a  subsequent 
chapter.  The  superficial  lymphatics  upon  the  palmar 
surface  pursue  the  shortest  course  to  the  dorsum.  Thus, 
for  instance,  an  infection  starting  upon  the  distal  part 
of  the  palm  would  go  between  the  web  of  the  fingers 
to  the  subcutaneous  tissue  of  the  dorsum.  Hence, 
should  an  abscess  develop  as  a  result  of  this,  it  would 
be  found  in  the  dorsal  subcutaneous  area.  Should  a 
lymphangitis  be  present,  however,  without  localized 
abscess  formation,  the  swelling  in  this  region  would 
be  just  as  great,  owing  to  the  edema  which  develops 
in  the  loose  tissue  found  here.  This  will  be  brought 
out  later  in  discussing  the  diagnosis.    Should  the  deep 


INVOLVEMENT  OF  FJSCLIL  SPACES  IN  TIIV  HAND     175 

hniphatics  be  imolvcd,  the  inffclion  will  lollow  the 
deo{X*r  vessels,  hence  passini;  into  the  ])alni.  Tlico- 
rctically  speakiii.u,  then,  an  inrcclioii  si)rca(Iin;<  from 
the  adjacent  sides  of  the  hllle  and  ring  finger,  and  the 
ring  and  middle  fnigers,  would  lead  to  an  accunuilation 
of  pus  in  the  middle  i)almar  spac-e,  while  an  infection 
of  the  adjacent  sides  of  the  middle  and  index  fingers 
and  index  and  thumb  would  infect  the  thenar  space. 
Other  infections  upon  these  fingers  more  dorsal  would 
follow  the  deep  vessels  under  the  aponeurosis  upon  the 
back  of  the  hand,  thus  producing  a  subaponeurotic 
abscess.  Unfortunatel)',  suf^cient  clinical  evidence 
has  not  accumulated  to  prove  these  assumptions, 
although  some  cases  have  been  reported  which  tend 
to  support  them.  Chevalet  and  Dolbeau,  particularly, 
have  presented  cases  showing  this  complication,  espe- 
cially those  showing  extension  and  development  of 
abscesses  under  the  dorsal  aponeurosis.  The  proof 
of  an  extension  to  the  palmar  and  thenar  spaces  is 
much  harder  to  demonstrate,  for  the  reasons  that 
have  already  been  pointed  out.  But  with  the  accurate 
outlines  of  the  spaces  that  we  have  shown  in  mind, 
it  is  to  be  hoped  that  the  future  will  enable  us  to  be 
more  definite  upon  this  point. 

Dolbeau  has  drawn  attention  to  the  frequency  of 
infection  along  the  course  of  the  radial  in  the  forearm, 
due  to  extension  from  the  thenar  region,  by  means  of 
the  radial  lymphatics.  He  also  notes  the  presence  of 
abscesses  along  the  ulnar  artery  and  in  the  deep  tissues 
in  the  forearm,  originating,  he  believes,  b>-  a  lymphatic 
extension  along  the  anterior  interosseous.  That  these 
all  occur  is  not  only  possible,  but  probable;  but  in  this 
connection  the  reader  will  remember  the  experimental 
injections  of  the  palmar  space,  and  the  ulnar  and  radial 
bursa?  where  the  mass  spreads,  In"  continuit\  of  tissue, 
under  the  tendons  into   this  middle  fo)er,   and   then 


176  PATHOGENESIS 

involved,  secondarily,  both  the  radial  and  ulnar  areas 
mentioned  (Experiments  46  to  49),  demonstrating  that 
the  same  clinical  signs  and  pathological  condition  can 
be  produced  by  fascial  space  or  synovial  sheath  exten- 
sion as  by  the  lymphatic  course,  except  those  cases  in 
which  the  radial  and  ulnar  foyers  are  the  primary 
source,  or  are  alone  involved. 

Recapitulation  as  to  Source  of  Involveme'nt 
OF  THE  Fascial  Spaces. — Given  a  distinct  space,  from 
what  source,  in  a  majority  of  cases,  is  it  likely  to  become 
involved,  leaving  out  of  consideration  direct  implanta- 
tion of  infection  ? 

The  middle  palmar  space  would  receive  infection 
from  the  middle  finger,  ring  finger,  and  radial  side  of 
the  little  finger,  with  their  synovial  sheaths  and  the 
corresponding  lumbrical  muscle  spaces.  Osteomyelitis 
of  the  middle  or  ring  metacarpals  would  also  extend 
to  this  space. 

The  thenar  space  would  become  involved  by  infec- 
tion from  the  index  finger  and  the  ulnar  side  of  the 
thumb  and  their  synovial  sheaths,  especially  that  of 
the  index  finger  and  the  index  lumbrical  space.  Osteo- 
myelitis of  the  index  and  thumb  metacarpals  could  also 
involve  this  space,  although  it  would  be  possible  for 
either  of  them  to  be  the  seat  of  disease  and  not  involve 
the  space. 

The  hypothenar  space  would  become  involved  in  an 
osteomyelitis  of  the  fifth  metacarpal. 

The  subaponeurotic  space  would  become  involved  by 
an  osteomyelitis  of  the  middle  and  ring  finger  meta- 
carpals particularly,  and  at  times  from  the  little  and 
index  metacarpals.  Lymphatic  abscesses  along  the 
deep  dorsal  vessels  would  also  lie  under  this  sheet  of 
tissue. 

The  dorsal  subcutaneous  space  communicates  freely 
with  the  fingers  and  the  thumb. 


INVOLVEMENT  OF  FASCIAL  SPACES  IN  71/ F  HAM)     177 

The  lumbrical  spaces  would  be  involved  by  extension 
from  a  tendon  sheath  infection  from  either  side  and 
from  an  infection  at  the  web  between  the  fingers  or 
a  "collar-button"  abscess. 

Extension  from  One  Fascial  Space  to  Another. 
—  In  the  preceding  section  we  have  answered  the  ques- 
tion as  to  the  source  of  involvement  of  the  various 
spaces.  We  now  arrive  at  the  next  question  which 
confronts  the  surgeon.  With  a  given  space  already 
involved,  to  what  other  spaces  could  the  infection 
extend,  and  by  what  course  ?  The  question  now  becomes 
one  more  of  pathology  than  anatomy,  and  while  the 
infection  still  retains  its  full  relation  to  the  anatomical 
peculiarities  of  a  part,  yet  the  destruction  of  tissue 
incident  to  long  inflammation  must  be  taken  into  con- 
sideration. The  longer  one  studies  the  question  the 
more  prone  he  is  to  ask  whether  many  of  the  compli- 
cating extensions  are  not  due  either  to  inadequate 
treatment,  or  an  improper  idea  as  to  the  position  of 
the  pus,  and  consequently  the  institution  of  incisions 
which  tend  to  favor  the  extension  of  the  infection  as 
much  as  to  give  proper  drainage. 

Let  us  take  the  pahnar  space.  Here  the  question 
of  extension  has  been  studied  by  injection.  The  pus 
would  have  a  natural  tendency  to  spread  in  two  ways: 
First,  along  the  lumbrical  muscles  of  the  little,  ring, 
and  middle  fingers,  and  thus  point,  in  time,  in  the  con- 
nective tissue  of  the  web  upon  the  dorsum.  This  we 
know  has  occurred  in  long-standing  cases,  in  spite  of 
the  pseudoclosure  of  the  canal  at  the  lower  end  and 
its  narrowness,  which  would  thus  favor  closure  by 
inflammatory  exudate  (see  x'-ray  plate.  Fig.  41,  and 
schematic  drawing,  Figs.  39  and  45).  Secondly,  the 
pus  would  tend  to  pass  under  the  annular  ligament 
behind  the  tendons,  immediately  over  the  wrist-joint, 
thence  into  the  forearm,  lying  upon  the  radius,  ulna, 


178  PATHOGENESIS 

interosseous  membrane,  and  its  attached  muscles,  and 
the  pronator  quadratus,  covered  by  the  flexor  pro- 
fundus digitorum,  thus  filhng  the  entire  space  from  the 
elbow  to  the  wrist  before  it  comes  to  the  surface  later- 
ally two  to  three  inches  above  the  wrist-joint  (Experi- 
ment 49).  This  extension  would  take  place  in  at  least 
two-thirds  of  the  injections  of  the  palmar  space  if 
force  were  used.  But  now  enters  the  question  of 
destruction  of  tissue  at  the  wrist-joint,  swelling  of  the 
tissues  under  the  annular  ligament,  and  the  plastic 
exudate,  which  would  tend  to  close  this  natural  exit. 
That  this  occurs  in  a  majority  of  the  cases  we  have 
abundant  clinical  evidence.  I  have  not  had  a  single 
case  in  which  pus  extended  from  the  middle  palmar 
space  to  the  forearm,  but  in  corroboration  of  the  experi- 
mental data  we  find  the  report  of  a  postmortem  done 
by  Professor  Dolbeau,  and  reported  by  Chevalet  in 
his  Paris  thesis  of  1875.  The  extension  under  the  syno- 
vial sheath,  without  invading  it,  and  the  involvement 
of  the  forearm,  with  its  diverticulum  along  the  radial, 
all  make  a  picture  the  duplicate  of  Experiment  49. 
It  will  be  noted  that  the  pus  occupies  the  exact  outlines 
of  the  middle  palmar  space,  bathes  the  free  portions 
of  the  tendons  in  juxtaposition  to  the  palmar  aponeu- 
rosis, and  yet  it  is  specifically  stated  that  the  abscess 
cavity  laid  dorsal  to  the  tendons. 

Case  IX. — "At  the  hand  the  lesion  is  limited  to  the 
middle  palmar  region;  the  two  eminences,  thenar  and 
hypothenar,  are  intact.  In  the  middle  palmar  region 
the  aponeurosis  is  raised  with  some  difhculty,  the  tissues, 
infiltrated  with  plastic  matter,  form  a  thick  layer  as 
if  lardaceous,  in  the  deep  part  of  which  are  plunged 
the  superficial  palmar  arch  and  the  terminal  ramifica- 
tions of  the  median  nerve. 

"These  organs  being  dissected  and  raised,  one  begins 
to  uncover  the  tendons  in  their  palmar  portion,  and  in 


^- 


INVOLVEMENT  OF  F ASCI. 11.  SP.ICEH  IN  THE  II. I M)     170 

order  to  be  able  to  examine  them  in  their  whole  length, 
the  annular  ligament  of  the  carpus  is  incised. 

"The  sheath  of  the  tendon  of  the  long  flexor  of  the 
thumb  is  intact  in  all  its  length,  at  the  thumb,  at  the 
l)alm  of  the  hand,  under  the  annular  ligament,  and 
above  this  ligament  the  cul-de-sac  by  which  it  termi- 
nates. Let  us  recall  that  it  is  upon  the  thumb  that  the 
initial  wound  is  found,  the  point  of  departure  of  all 
the  trouble.  But  the  sheath  of  the  flexor  longus  polliris 
is  absolutely'  intact. 

"  In  examining  the  ulnar  sheath  one  finds  the  follow- 
ing: The  portion  of  this  sheath  destined  to  cover  the 
tendons  of  the  superficial  flexor  is  little  altered,  and 
these  tendons,  save  that  of  the  little  finger,  are  rela- 
tively intact.  The  portion  of  the  sheath  destined  to 
the  tendons  of  the  deep  flexor  is  much  more  diseased, 
especially  at  the  level  of  the  tendon  of  the  little  finger. 
In  examining  the  sheath  of  this  tendon,  one  finds  it 
intact  in  its  digital  portion.  The  tendon  presents  there 
its  mother-of-pearl  appearance,  and  is  absolutely  sound. 
But  if  one  follows  it  to  the  palm  of  the  hand,  one  sees 
it  penetrate  into  a  purulent  foyer,  which  occupies  the 
deep  part  of  the  hand.  The  tissue  about  bathed  in 
pus  is  diseased.  Likewise  the  tendons  which  it  en- 
velops for  a  stretch  of  about  4  cm.  of  the  tendon  of 
the  little  finger,  of  2.5  cm.  to  3  cm.  of  the  other  tendons, 
index,  middle,  and  ring.  Above  this  point  the  sheath 
and  the  tendons  take  again  their  character  of  integrity 
and  keep  it  in  the  carpal  canal,  even  to  the  terminal 
cul-de-sac  of  the  sheath. 

"  In  raising  the  tendonsof  the  deep  flexor,  one  begins 
to  uncover  a  purulent  foyer  occupying  the  profound 
palmar  region,  situated  exactly  upon  a  median  line 
(par  rapport)  in  relation  to  the  axis  of  the  hand,  and 
corresponding  exactly  to  the  deep  palmar  arch  that 
one  sees  placed  against  its  posterior  wall.     Us  anterior 


180  PATHOGENESIS 

wall  is  formed  by  the  sheath  of  the  deep  flexor  tendons 
that  it  flooded  over.  It  is  prolonged  the  length  of  the 
sheath  of  the  tendon  of  the  little  finger,  had  opened  it 
and  pus  had  penetrated  and  traversed  it  in  such  a 
manner  as  to  come  to  show  itself  beneath  the  palmar 
aponeurosis;  but,  a  thing  to  notice,  it  had  not  spread 
into  this  sheath,  neither  at  the  lower  part,  toward  the 
little  finger;  more  in  the  upper  part  in  the  carpal 
canal. 

"The  radiocarpal  articulation  is  filled  with  pus; 
its  cartilages  are  destroyed,  the  osseous  surfaces  which 
supported  them  are  eroded.  The  triangular  ligament 
partly  destroyed  allows  the  radiocarpal  articulation  to 
communicate  freely  with  the  inferior  radiocubital 
articulation. 

''The  articulation  of  the  first  row  of  the  carpal  with 
the  second  is  in  the  same  condition ;  likewise  the  artic- 
ulation of  the  bones  of  each  row  between  them, 
especially  of  the  first.  What  is  the  origin,  what  has 
been  the  mode  of  production  of  this  suppurative 
arthritis  of  the  wrist?  It  is  a  question  not  easy  to 
decide,  but  that  which  can  be  affirmed  is  that  the 
lesion  so  limited  by  the  sheath  has  not  been  there  for 
nothing,  since  this  sheath  is  intact  at  the  level  of  the 
articulation. 

"  In  dissecting  the  forearm,  one  is  struck,  first  of  all, 
by  the  apparent  integrity  of  its  anterior  region.  The 
lesions  are,  in  fact,  very  deep.  Alone,  the  sheath  of 
the  radial  vessels  appears  diseased  from  the  first 
inspection.  It  is,  in  the  inferior  half  of  the  forearm 
region,  infiltrated  with  a  plastic  matter  which  gives  to 
it  the  appearance  of  a  whitened  cord  with  granulated 
surface.  The  artery,  plunged  in  the  middle  of  this 
plastic  matter,  is  detached  from  it  only  with  difficulty, 
and  by  dissecting  it  with  care.  The  sheath  of  the  ulnar 
is  intact;   the   median   nerve   presents  nothing  at  all 


INVOLVEMENT  OV  F.ISCI.II.  SV.ICES  IN   'IIIV  HAND     181 

l)arlicular;  the  iiuisclcs  arc  intact  also;  at  least  those 
of  the  sui)erficial  layers,  because  in  dissecting  the  deej) 
flexor  one  finds  beneath  it,  or  rather  in  its  thickness, 
in  front  of  and  inside  of  the  ulnar  bone,  a  purulent 
foyer  of  about  the  volume  of  a  small  egg.  This  fo>-er, 
situated  at  the  middle  part  of  the  forearm,  well  limited 
below,  at  least  upon  the  anterior  region  of  the  forearm, 
is  without  communication  with  the  lesion  (jf  the  i)alm 
of  the  hand,  and,  with  that  which  we  shall  see  presently, 
exists  at  the  level  of  the  pronator  quadratus.  In  seek- 
ing what  has  been  its  point  of  departure,  one  finds 
it  at  the  side  of  the  ulnar  bone.  This  latter  has  been 
the  seat,  in  its  inferior  half,  of  the  suppurative  perios- 
titis, and  is  almost  totally  denuded,  even  to  the  middle 
of  its  length.  The  foyer  that  we  have  just  indicated 
is  a  tributary  of  the  subperiosteal  foyer  which  bathes 
the  bone  from  the  back  and  the  inside.  The  origin 
of  this  periostitis  appears  to  have  been  the  rupture  of 
the  articulation  full  of  pus,  which  was  opened  from  the 
back. 

"  In  raising,  at  the  wrist,  all  the  tendons,  the  flexors, 
one  begins  to  uncover  a  second  foyer  situated  between 
these  tendons  and  the  pronator  quadratus.  This 
muscle,  altered  but  not  destroyed,  separates  this  foyer 
from  the  ulnar  bone,  so  that  there  exists  no  relation 
between  it  and  the  osseous  lesion.  On  the  contrary, 
this  foyer  communicates  by  the  proper  canal,  behind 
the  sheaths  of  the  tendon,  with  the  palmar  foyer." 

We  now  ask  ourselves,  What  are  the  probabilities 
for  extension  when  these  normal  exits  are  closed?  In 
what  way  will  the  inflammatory  destruction  of  barriers 
show  itself?  The  pus  cannot  break  through  the  firm 
palmar  aponeurosis.  We  first  turn  our  attention  to 
the  adjacent  thenar  space.  We  remember  that  the 
lower,  or  distal  portion  of  the  intervening  wall  is  very 
firm,  but  that  at  the  proximal  end  the  dividing  tissue 


182  .  PATHOGENESIS 

is  rather  thin,  and  it  is  very  easy  to  suppose  that  the 
infection  may  destroy  this  and  thus  invade  the  radial 
side.  Experimentally,  this  can  be  seen  to  occur  (Ex- 
periment 20,  Fig.  41).  This,  however,  would  not 
occur  until  late,  since  most  of  the  pus  is  at  the  distal 
part  of  the  hand.  But  that  it  does  occur  frequently 
in  neglected  cases  I  have  abundant  clinical  evidence. 
It  is  one  of  the  most  common  of  the  extensions. 

Again,  the  pus  might  extend  along  the  lumbrical 
muscle  of  the  middle  finger,  and  rupture  from  here 
into  the  thenar  area. 

Upon  the  hypothenar  side  there  is  so  much  tissue 
intervening  between  the  middle  palmar  space  and  the 
hypothenar  that  we  would  expect  this  to  become 
involved  only  in  exceptional  cases. 

Text-books  all  tell  us  that  the  pus  in  these  cases 
finds  exits  between  the  metacarpal  bones,  and  thus 
escapes  to  the  dorsum.  When  one  studies  the  dense 
layer  of  fascia  spreading  from  bone  to  bone,  upon  both 
the  volar  and  dorsal  surfaces,  being  really  an  anterior 
and  posterior  interosseous  membrane,  with  the  inter- 
osseous muscles  between,  and  a  division  between  them 
being  often  difficult  to  find,  we  are  led  to  wonder  if 
this  complication  really  occurs  as  early  in  the  course 
of  the  disease  as  we  are  led  to  believe.  Whether  often 
the  edema  upon  the  dorsum  may  not  have  been  mis- 
taken for  pus,  and  the  spurious  corroboration  obtained 
by  through-and-through  drainage  misinterpreted.  By 
no  means  can  it  be  denied  that  at  times,  later  in  the 
course,  the  pus  does  find  this  means  of  exit.  When 
it  does,  it  first  comes  to  lie  in  the  subaponeurotic, 
and  then  in  the  subcutaneous  tissue.  I  personally 
have  never  seen  such  a  case  unless  there  was  an  osteo- 
myelitis of  the  metacarpals  or  carpal  bones,  and  I 
believe  it  to  be  uncommon. 

Another   cause   of   extension   is   sometimes   seen   in 


I  \  I  oi.i  i:\i i:\'r  or  r.isci.ii.  sr.ici.s  i\  nil:  ii.ind    \k^ 

which  ihi'  iihicir  biii'sal  >h(ath  is  dcslrox cd,  and  [His 
thus  entiTs  {\\v  sac,  spn-ads  aloiii;  ihc  Iciidons,  and 
ruptures  into  the  roreariii  in  the  same  space  \vc 
have  ah'ead}'  descril)ed  as  lying  under  the  flexor 
profundus. 

Suppose  our  thenar  space  to  be  primarily  involved; 
the  pus  here  does  not  so  readily  extend  into  the  fore- 
arm (Experiments  forcible,  Nos.  29  to  33).  Here 
probabiy  the  weakest  place  lies  toward  the  dorsum, 
either  above  or  below  the  adductor  transversus,  thus 
invading  the  tissue  between  the  thumb  and  index 
metacarpal,  and  between  the  adductor  transversus  and 
first  dorsal  interosseous,  where  there  is  a  large,  cone- 
shaped  cavity  (see  Experiments  Nos.  29  to  32).  It 
should  be  borne  in  mind,  however,  that  this  result  is 
not  obtained  easily,  since  the  pus  will  often  remain 
for  days  confined  to  the  thenar  space  (Case  X).  In 
long-continued  or  anomalous  cases  it  can  spread  up 
along  the  lumbrical  muscle  of  the  index  finger,  infect 
the  loose  connective  tissue  about  the  palmar  tendons, 
and  thus  infect  the  palmar  space,  or  can  rupture 
through  at  the  upper  end  (Experiments  29  to  35). 
This  complication  should  be  rare,  however,  in  properly 
treated  cases. 

In  case  the  subaponeurotic  space  is  infected  by  ex- 
tension from  the  palmar  space  or  otherwise,  there 
might  be  considerable  variation  in  the  course  the  pus 
would  pursue;  if  the  sheet  is  dense,  as  it  is  in  a  majority 
of  cases,  the  suppurative  process  would  tend  to  extend 
under  the  aponeurosis  and  point  lateralh',  upon  either 
side,  at  the  thinner  tissue  there,  thus  becoming  subcu- 
taneous, or  at  the  distal  margin  between  the  metacar- 
pophalangeal joints,  as  I  myself  have  seen.  However, 
at  times  there  are  thin  places  between  the  tendons, 
and  then  the  purulent  matter  would  become  sub- 
cutaneous through  this  small  opening.       In  all   prob- 


184 


PATHOGENESIS 


ability,  however,  before  any  of  these  things  happen, 

operative  interference   will   have   opened   the   abscess 

(Fig.  64). 

Fig.  64 


Scars  showing  where  subaponeurotic  abscess  has  pointed.  Note  four 
openings  at  the  edge  of  the  aponeurotic  sheet.  Note  prominence  of  tendons, 
i.  e.,  suppuration  beneath. 


chaptp:r  XI I 

THE  Sr^RKAD  OF  IXFKCTION  FROM  ANY 
GIVEN  PRLMARY  FOCUS 

This  will  be  discussed  under  three  heads — the  pos- 
sible spread  from  jDrimary  foci  on  the  fingers,  from 
foci  on  the  palm,  from  foci  on  the  dorsum. 

THE  PROBABLE  EXTENSIONS  FROM   PRIMARY  FOCI  ON  THE 

FINGERS 

The   Spread  of   Infection   In\olving   the    Index   Finger 

The  index  finger  having  received  a  severe  injury, 
causing  a  deep  infection,  we  admit  that  the  infection 
can  spread  by  three  methods:  (a)  Lymphatic;  (b) 
fascial ;  (c)  through  the  synovial  sheath.  The  subject  of 
lymphatic  extension  is  discussed  in  Chapter  XXI.  The 
extension  b^^  the  fascial  spaces  is  easy  to  follow  when 
we  study  the  series  of  cross-sections  (Figs.  19  to  26). 
Here  we  see  there  is  loose  connective  tissue  surround- 
ing the  phalanges  in  which  it  could  spread  with  only 
moderate  difficult}' ;  upon  the  dorsum  it  might  go  up 
into  the  subcutaneous  tissue  in  the  back  of  the  hand. 
Internally,  it  would  come  to  lie  in  the  cellular  spaces 
at  the  web  between  the  index  and  middle  fingers,  and 
could  even  spread  along  the  lumbrical  muscle  of  the 
middle  finger  into  the  palm,  and  thus  invade  the  middle 
palmar  space.  This,  however,  would  be  more  likely 
to  occur  in  a  deep  inflammation  involving  the  proximal 
phalanx  of  the  middle  finger,  if  at  all;  since,  as  a  general 
rule,  the  pus  would  come  to  the  surface  before  extending 
along  the  lumbrical  canal. 


186     INFECTION  FROM  ANY  GIVEN  PRIMARY  FOCUS 

Upon  the  radial  side  of  the  index  finger  thece  would 
be  still  less  likelihood  of  the  pus  entering  the  lumbrical 
canal  in  preference  to  coming  to  the  surface,  since 
this  canal  is  not  so  well  marked.  Of  course,  it  could 
not  extend  upon  the  volar  side  into  the  palm,  because 
there  is  no  connecting  space  (see  cross-sections  20  and 
22).  Again,  we  note  that  if  the  pus  were  under  the 
dorsal  aponeurosis  of  the  proximal  phalanx,  it  would  be 
limited  to  this  area,  since  it  is  a  closed  space  and  does 
not  communicate  with  the  subaponeurotic  foyer  upon 
the  dorsum  of  the  hand.  Thus,  we  see  that  while  it  is 
possible  for  the  thenar  space  to  become  infected  by 
fascial  space  extension,  it  is  not  probable.  However, 
a  metacarpophalangeal  arthritis  may  develop  with 
destruction  of  the  bone  and  ligaments.  This  extension 
then  becomes  not  only  possible,  but  probable,  since 
the  metacarpal  bone  of  the  index  finger  lies  in  juxta- 
position to  the  thenar  space,  separated,  however,  in 
part,  by  the  adductor  transversus.  Pus  would  prob- 
ably first  enter  the  space  between  the  adductor  trans- 
versus. and  the  first  dorsal  interosseous,  then  pass  into 
the  thenar  space. 

The  question  now  arises,  however,  Should  the  pus 
lie  either  primarily  or  secondarily  in  the  subcutaneous 
tissue  upon  the  dorsum  of  the  hand  in  the  region  of 
the  index  metacarpal,  could  it  spread  around  the  radial 
border  of  the  index  metacarpal  into  the  thenar  space? 
Again,  should  it  lie  in  the  subcutaneous  tissue  between 
the  index  and  thumb  metacarpals,  could  it  pass  under 
the  web  into  that  space?  The  study  of  the  cross- 
sections  (Figs.  65  and  66)  as  well  as  the  experimental 
injections  (Nos.  39  and  40)  seem  to  show  that  this  is 
not  probable.  Clinical  evidence  can  be  adduced  to 
corroborate  this.  The  pus  would  rather  come  to  the 
surface  upon  the  dorsum.  The  subaponeurotic  ac- 
cumulations, unless  complicated  by  an  osteomyelitis. 


iMi-cTiox  imoijim:  the  i\i>i:x  iiscek       is7 

would    also    lolluw    (he    same  (oiiisc    Kcc    I-Apcriniciils. 

4;^  to  45)- 

\\  r  now   come  lo  tlu-  lliird  mrllKxlol  cxtfiisioii      l^y 

the   index  synovial  shcatli.      Let   us  supi)()sc  thai   the 

Fig.  65 


D5C5       V     iM 


DIM         M 


Cross-section  No.  V. — 35  cm.  proximal  to  joint.  Lettering  common  to 
all  plates:  55,  synovial  sheath;  Z55C5,  dorsal  subcutaneous  space;  DSAS, 
dorsal  subaponeurotic  space;  ECT,  extensor  communis  tendon;  FT,  flexor 
tendon:  LM,  lumbrical  muscle;  IM,  interossei  muscles;  M,  metacarpal 
bone ;  B  V,  bloodvessels ;  N,  nerves ;  TS,  thenar  space ;  MPS,  middle  palmar 
space;  ATP,  adductor  transversus  poUicis;  DIM,  dorsal  interosseous  mem- 
brane; PIM,  palmar  interosseous  membrane;  UB,  ulnar  bursa;  IS,  space 
between  adductor  transversus  and  first  dorsal  interosseous;  DIM,  dorsal 
interosseous  membrane;  FLP,  flexor  longus  pollicis  in  its  synovial  sheath; 
HM,  hypothenar  muscles  with  intermuscular  spaces;  IV,  interosseous  vessels 
and  nerve. 

synovial  sheath  has  become  filled  with  pus  and  an  ex- 
tension taken  place  into  the  hand  along  this  sheath. 
Here  the  anatomical,  experimental,  and  clinical  e\i- 
dencc    is    clear     (cross-sections.     Figs.    65     and    66; 


188     INFECTION  FROM  ANY  GIVEN  PRIMARY  FOCUS 

Experiments  8,  9,  27,  and  35;  Case  X).  Having 
ruptured  from  the  proximal  end  of  the  sheath,  where  it 
is  very  thin  generally,  the  pus  would  lie  in  the  loose 
connective  tissue  which  surrounds  this  tendon  and  the 
lumbrical  muscle.  After  a  short  time,  as  the  infection 
persisted,  or  the  accumulation  of  pus  grew,  it  would 
follow  the  lines  of  least  resistance,  and  run  along  the 
lumbrical  muscle  toward  the  radial  side  of  the  index 

Fig.  66 


D5CS     P]M  IM  M 


Cross-section  No.  VI. — Through  distal  part  of  thenar  area.  See  Fig.  63 
for  common  lettering:  ITS,  indefinite  thenar  spaces;  TMF,  tendon  of  middle 
finger;  TM,  thenar  muscles;  PF,  palmar  fascia;  RA,  radial  artery;  DP  A, 
deep  palmar  arch — digital  branches  beginning ;  DIA ,  dorsalis  indicis  artery. 

finger  (Experiment  8,  Fig.  40),  and,  being  Hmited  here, 
would  then  rupture  through  the  thin  sheet  of  fascia, 
separating  this  tissue  from  the  thenar  space  (cross- 
sections.  Figs.  65  and  66),  and  thus  become  a  thenar 
space  infection.  (For  a  complete  discussion  of  tendon- 
sheath  extensions,  see  Chapters  IX  and  XII.) 
The  following  case  corroborates  these  deductions : 
Case  X. — Seen  in  the  service  of  Prof.  F.  A.  Besley 
at  the  Post-Graduate  Hospital, 


INFECTION  INVOLVING  THE  INDEX  fINCEK         ISO 

Diagnosis:  Infected  wound  of  index  finger,  teno- 
synovitis of  index  tendon,  infection  thenar  space,  ulti- 
mate amputation  of  finger. 

September  2,  1904.  T.  W.  Ten  days  before  coming 
to  the  hospital  the  patient  cut  his  finger  just  above  the 
knuckle-joint  on  a  tin  can;  wound  slightly  to  radial 
side  of  dorsum.  This  became  infected,  and  the  patient 
consulted  a  physician,  who  opened  the  wound  and 
passed  a  drainage  tube  through  and  across  dorsum, 
coming  out  between  the  index  and  middle  fingers. 
Upon  examination  the  finger  was  seen  to  be  much 
swollen,  as  was  the  entire  hand,  particularly  the  dor- 
sum. Several  openings  appeared  about  the  proximal 
phalanx.  A  probe  into  one  of  these  found  rough  bone 
and  easily  entered  the  knuckle-joint.  The  entire  finger 
and  hand  were  slightly  tender,  but  marked  and  con- 
spicuous tenderness  was  elicited  over  the  site  of  the 
tendon  sheath,  and  sharply  limited  by  it,  being  most 
acute  at  proximal  end,  over  the  metacarpophalangeal 
articulation.  Flexion  of  finger  did  not  increase  pain; 
extension  of  index  finger  caused  marked  pain  through 
finger,  but  most  sharply  noted  by  patient  at  proximal 
end  of  sheath.  Extension  of  other  fingers  caused  little 
increase  of  pain ;  no  particular  pain  on  dorsum  of  finger 
where  cuts  were  found.  Temperature,  101°;  pulse,  92. 
Infection  of  foot  present  also,  as  well  as  small  boil  on 
opposite  shoulder.  Epitrochlear  and  axillary  glands 
swollen  out  of  proportion  to  those  in  left  arm.  (Pa- 
tient's resistance  is  evidently  far  below  par.)  Systemic 
vSymptoms  marked.     Neutrophilia,  94  per  cent. 

Clmical  Diagnosis:  Infected  wound  of  hand;  prob- 
ably staphylococcus;  infected  index  tendon  sheath; 
extension  to  glands  of  axilla  and  elbow  and,  in  addition, 
infection  of  skin  on  shoulder  and  in  foot.  Etiology  of 
latter  unknown — possibly  p\emic  from  hand;  infected 
knuckle-joint. 


190     INFECTION  FROM  ANY  GIVEN  PRIMARY  FOCUS 

Prognosis:  Will  probably  lose  finger. 

Operation:  Tendon  sheath  opened  from  end  to  end. 
Pus  in  moderate  amount  evacuated.  Dorsal  openings 
previously  present  enlarged.  Hot  boric  dressings. 
Foot  opened  and  drained.  Temperature  ran  99°  to 
101°  every  day. 

September  9.  Finger  shows  fluctuation  on  dorsum 
of  hand  just  proximal  to  index  finger  and  ulnarly. 
Incision  and  drainage.  Finger  not  so  painful;  flexion 
about  same.  Not  so  tender;  no  special  swelhng  in 
palm  of  hand. 

September  12.  Infection  has  extended  to  thenar 
eminence;  tenderness  localized  to  this  area.  Swelhng 
marked;  palm  not  involved. 

Operation:  Inserted  forceps  into  cut  on  dorsum  made 
September  9;  forceps  fell  into  direct  communication 
with  volar  surface  of  thenar  eminence;  opened  here; 
pushed  forceps  then  from  volar  surface  through  to 
dorsum  between  first  and  second  metacarpals;  forceps 
passed  through  dorsal  skin  with  little  or  no  resistance; 
drainage  inserted. 

September  15.  Subcutaneous  abscess  has  developed 
in  radial  region  of  forearm  above  wrist  and  above 
elbow,  and  over  brachial  vessels;  incised  and  drained. 
White  blood  cells,   18,000. 

September  24.    Temperature,  99°  to  101°. 

October  14.  Temperature  has  been  running  99° 
to  100°  for  last  two  weeks;  index  finger  swollen  to  four 
times  its  normal  size;  blue,  and  evidently  an  osteo- 
myelitis of  the  proximal  phalanx,  and  a  suppurative 
arthritis  of  metacarpophalangeal  joint. 

Operation:  Index  finger  and  head  of  metacarpal  bone 
amputated;  drainage. 

October  20.     Condition  of  hand  much  better. 

Following  this  the  patient  improved  rapidly;  dis- 
charged. 


INFECTIOS  IM  (J I. rise.   THE  MIDDI.K  II ACER        I'Jl 

November  3,  1904.  Small  area  of  j^ranulalioii  tissiu- 
over  ami)utated  area;  moves  thumb  and  ihrcc  fingers 
three-fourths  of  normal;  wrist-joint  same;  function  of 
all  will  nltimateh'  be  restored. 

The  Spread  of  Infection  Involving  the  Thumu 

Infection  of  the  thumb  would  at  first  glance  seem  to 
offer  the  most  favorable  course  for  pus  to  extend  into 
the  thenar  space.  But  let  us  consider  for  a  moment. 
Lymphatic  extension  does  offer  some  chance,  if  the 
infection  be  deep  and  upon  the  ulnar  side,  as  will  be 
pointed  out  (Chapter  XX,  and  Fig.  99).  Upon  the 
other  parts,  however,  the  tendency  would  be  for  the 
pus  to  be  carried  away  from  the  space. 

The  synovial  sheath  of  the  flexor  longus  pollicis  lies 
some  distance  from  the  space,  and  hence  pus  would 
tend  to  come  to  the  surface  if  the  sheath  ruptured  in 
its  course.  It  can  be  seen,  however,  that  if  the  sheath 
ruptured  in  its  distal  part,  and  the  infection  thus 
became  an  infection  of  the  connective-tissue  spaces, 
it  could  spread  along  the  ulnar  side  of  the  thumb,  and 
by  considerable  destruction  of  connective  tissue  come 
to  lie  upon  the  origin  of  the  adductor  transversus, 
and  thus  invade  the  space.  In  the  majority  of  cases, 
however,  the  pus  would  rupture  from  the  sheath  into 
the  forearm.  (For  a  complete  discussion  of  tendon- 
sheath  extensions,  see  Chapters  XII  to  XIV.) 

Should  the  infection  be  upon  the  back  of  the  thumb, 
the  pus  would  extend  more  easily  into  the  dorsal  sub- 
cutaneous tissue  of  the  thenar  area,  while,  in  all  probabil- 
it3^  upon  its  radial  side  it  would  point  upon  the  surface. 

The  Spread  ov  Infection   Invoiatng  the  Middle  Finger 

Here  the  linger,  King  as  it  does  in  the  dividing  line 
between  the  thenar  and  middle  palmar  spaces,  becomes 
an  extremely  inleresting  subject  of  study.     The  Km- 


192     INFECTION  FROM  ANY  GIVEN  PRIMARY  FOCUS 

phatic  extension  has  already  been  touched  upon  and 
will  be  discussed  further  in  Chapters  XX  to  XXIV. 

Extension  from  the  synovial  sheath  at  its  proximal 
end  gives  positive  results  experimentally  (Experiments 
I  and  2),  since  in  every  case  the  mass  extended  into 
the  middle  palmar  space  after  rupturing  through  the 
indefinite  connective  tissue,  separating  it  from  the 
space,  as  already  described  under  the  index  finger 
discussion.  It  is  to  be  borne  in  mind,  however,  that 
the  lumbrical  muscle  joining  this  tendon  comes  back 
to  pass  under  the  transverse  ligament,  between  the 
index  and  middle  fingers,  and  that  while  the  tissue 
intervening  between  this  muscle  and  the  thenar  space 
is  firm,  and  experimental  injections  have  failed  to 
rupture  through,  yet,  anatomically,  it  would  seem 
to  be  possible  in  some  cases.  Clinical  evidence  shows 
that  while  it  does  occur  this  extension  is  rare.  For  a 
complete  discussion  of  the  extensions  from  the  tendon 
sheaths,  see  Chapter  XIV.  Should  the  infection  be  a 
deep-seated  accumulation  of  pus  in  the  cellular  tissue 
upon  the  dorsum  it  could  spread  subcutaneously  upon 
the  back  of  the  hand ;  upon  the  radial  side  it  would  pass 
exceptionally  along  the  lumbrical  muscle  into  the 
middle  palmar  space,  with  the  possibility  of  invading 
the  thenar  space,  as  above  noted;  upon  the  ulnar  side, 
if  it  should  spread  along  the  lumbrical  muscle,  it  would 
go  into  the  middle  palmar  space  (Experiments  26  A, 
and  26  B) 

Subaponeurotic  infection  would  be  limited  to  the 
phalanx,  while  osteomyelitis,  involving  the  metacarpal 
bone,  would  tend  to  invade  the  middle  palmar  space 
in  front  and  the  subaponeurotic  on  the  back. 

The  Spread  of  Infection  Involving  the  Ring  Finger 

Here  there  is  little  doubt  about  the  relation  between 
this  finger  and  the  middle  palmar  space.     The  exten- 


INFECTION  SPREADING  FROM  TllK  IJTTIE  FINGER     VS.'> 

siuii  b>'  lIic  d(jrsal  subciilaiR'(jiis  tissue  nia>'  be  in  any 
direction.  The  lymphatic  extension  will  be  discussed 
in  Chapt<.'rs  XX  and  XXI.  The  connective-tissue 
spaces  at  either  side  of  the  finger  and  in  the  web  of 
the  infected  hand  allow  the  pus  to  spread  through  the 
fibrous  canal  surrounding  the  lumbrical  muscles  and 
lead  into  the  palmar  space  (see  Experiments  26  A  and 
26  B,  and  Fig.  37).  In  making  this  deduction  it  should 
be  emphasized  again  that  in  a  majority  of  cases  pus 
would  be  e\'acuated  on  the  surface  before  it  would 
burrow  through  this  canal.  Hence  it  is  only  in 
neglected  cases  that  this  complication  would  ensue, 
unless  extension  had  taken  place  by  the  lymphatic 
channels  which  pass  through  these  same  canals. 

Suppuration  extending  from  the  synovial  sheath 
would  enter  the  middle  palmar  space  (Experiments 
2,  4,  18,  19,  and  20;  cross-sections,  Figs.  65  and 
66).  Primarily,  of  course,  it  would  lie  in  the  loose 
connective  tissue  superficial  to  the  space,  spread  down 
along  the  lumbrical  muscles  (Fig.  36),  especially  of  the 
little,  ring,  and  middle  fingers,  and  then,  destroying 
the  thin  roof  of  the  space,  would  involve  the  entire 
middle  palmar  space.  (For  a  complete  discussion  of 
tendon  sheath  extensions,  see  Chapter  XIV.) 

Arthritis  of  the  metacarpophalangeal  joint,  with 
osteomyelitis  of  the  diaphysis  of  the  metacarpal,  could 
also  infect  this  space,  as  w^ell  as  the  subaponeurotic 
on  the  dorsum  (Case  VIII). 

Infection  Spreading  from  the  Little  Finger 

Here  the  lymphatic  channels  and  connective-tissue 
spaces  upon  the  inner  side  of  the  finger  could  lead  into 
the  middle  palmar  space,  although  such  extension  is 
uncommon.  On  the  outer  and  dorsal  side  they  would 
tend  to  lead  into  the  subcutaneous  tissue  externally. 
13 


194     INFECTION  FROM  ANY  GIVEN  PRIMARY  FOCUS 

The  synovial  sheath,  if  continuous  with  the  ulnar 
bursa,  would  probably  rupture  earliest  in  the  forearm 
(x-ray  plate.  Fig.  39).  (For  a  discussion  of  *  this,  see 
Chapters  IX  and  XIV.)  If  it  did  rupture  in  the  hand, 
or  if  the  synovial  sheath  of  the  finger  were  shut  off 
from  the  ulnar  bursa,  and  the  finger  sheath  ruptured, 
it  would  tend  to  involve  the  middle  palmar  space 
(Experiments  5  and  6).  It  might  be  mentioned 
here  that  Chevalet  and  Dolbeau  maintain  that  a 
rupture  of  the  sheath  is  not  necessary  to  extension, 
but  that  this  can  take  place  from  the  sheath  by  lym- 
phatic extension,  and  they  adduce  a  postmortem 
examination  in  support  of  their  contention.  This, 
however,  is  an  academic  question,  since  the  same  space 
would  be  involved  by  the  extension,  and  the  clinical 
findings  would  be  identical.  (For  a  complete  discussion 
of  the  tendon  sheath  extension,  see  Chapter  XIV.) 

In  an  osteomyelitis  of  the  fifth  metacarpal,  the 
hypothenar  space  would  be  involved  upon  the  volar 
surface  and  the  subcutaneous  tissue  dorsally  (cross- 
sections,  Figs.  65  and  66). 

Infections  Beginning  in  the  Palm  and  Dorsum 

When  a  primary  focus  appears  upon  the  palm,  if  it 
is  a  punctured  wound,  the  abscess  may  develop  in  any 
of  the  pockets  I  have  described,  if  implanted  there 
under  the  palmar  fascia'.  If  in  the  thenar  or  hypo- 
thenar area,  they  may  develop  local  abscesses  without 
entering  the  palmar  or  thenar  spaces.  If  the  infection 
develops  at  the  distal  part  of  the  palm  in  the  subcu- 
taneous or  lumbrical  spaces,  it  will  follow  the  course 
described  on  p.  208.  In  the  central  part  of  the  palm 
it  is  not  possible  for  large  abscesses  to  develop  between 
the  skin  and  the  palmar  fascia,  owing  to  their  intimate 
association.     Lymphatic  infections  in  the  central  part 


INFECTIONS  BEGINNING  IN  THE  P.II.M  .IM)  DORSUM     l!).') 

ot  llu'  palm  nia\'  imolvc  the  dcc-jjiT  part  ol  the  hand 
(Fi^'.  loi).  At  the  sides  the  infection  ])ursui-s  the 
shortest  course  to  the  hack  of  the  hand,  where  abscesses 
may  develop  subcutanecjusly.  At  the  j^roxinial  end  of 
the  pahn  secondary  lymphatic  abscesses  may  develop 
subcLitaneously  above  the  anterior  annular  ligament 
(see  Chapter  XIV). 

When  the  i)rimar>-  focus  develops  upon  the  dorsum, 
if  it  be  a  localized  abscess  it  will  be  either  in  the  sub- 
ctitaneous  or  subaponeurotic  spaces.  I  f  extension  takes 
place  by  contiguity  or  lymphatic  channels,  the  second- 
ary abscesses  lie  upon  the  dorsum  of  the  forearm  or  the 
glandular  areas  at  the  elbow  and  axilla. 


CHAPTER  XIII 

PATHOLOGY   OF  TENDON  SHEATH   AND 
FASCIAL  SPACE  ABSCESSES 

The  discussion  is  here  limited  to  changes  in  the 
tendons,  tendon  sheaths,  and  fascial  spaces.  The 
pathology  of  bone  changes,  arthritis,  and  secondary 
sequelae  in  the  hand  and  forearm  will  be  taken  up  later. 

A  classification  of  the  changes  incident  to  teno- 
synovitis may  be  made  as  follows: 

Primary.  A.  Changes  while  the  infection  is  limited 
to  the  sac:  (i)  Contents  of  sac,  serum,  tendon.  (2)  Wall 
of  sac.     (3)   Circulation,  lymphatics  with  edema. 

B.  When  rupture  of  the  sac  occurs:  (i)  Involvement 
of  the  fascial  spaces,  (a)  hand,  (&)  forearm.  (2)  Involve- 
ment of  the  nerves.  (3)  Involvement  of  joints.  (4) 
Involvement  of  bones. 

Secondary,  (i)  Tendon  adhesions.  (2)  Ankylosis  of 
joints.  (3)  Persistent  edema  and  hyperplasia  of  cellular 
tissue;  scar  contraction  with  subsequent  atrophy.  (4) 
Chronic  osteomyelitis. 

The  changes  occurring  in  the  section  under  "  Primary 
B,"  will  be  discussed  under  fascial  space  abscesses 
following,  and  the  ''Secondary"  changes  will  be  dis- 
cussed in  detail  in  later  chapters,  dealing  with  the 
complications  and  sequelse  of  infections  (see  Chapter 
XXVIII). 

THE  TENDON  SHEATH  PROPER 

Anyone  who  has  had  occasion  to  open  the  acutely 
inflamed  tendon  sheath  has  been  surprised  at  the  rapid 


THE  TENDON  SUE. IT//   /'/<() />ER  197 

change  which  has  taken  jilaci'.  The  clianges  are  com- 
parable to  a  pressure  necrosis,  but  whether  due  to  the 
great  toxicity  of  the  streptococcus  infection  or  the  great 
edema  about  and  the  efifusion  into  the  sheath,  shutting 
off  the  blood  supply,  may  be  a  question. 
The  serum  in  the  sac  in  the  more  acute  cases  is  nor- 
mally scanty  in  amount  and  only  slightly  tinted.  The 
consistency  varies  from  a  slightly  slimy  fluid  to  a  thick 
pus.  While  in  the  more  acute  varieties  the  amount  may 
at  times  be  very  great,  it  soon  ruptures,  and  on  operation 
we  may  find  little  or  much  in  the  sac;  in  the  more 
chronic  type  we  frequently  find  a  large  amount  of 
thick,  creamy  pus,  even  though  rupture  has  ensued. 

The  w^all  of  the  sac  is  congested  and  edematous  with 
the  exception  of  the  part  under  the  anterior  annular 
ligament  where  the  pressure  is  great.  Here  necrosis, 
not  alone  of  the  sheath,  but  also  of  the  tendons,  is 
prone  to  occur.  While  we  may  find  the  synovial  wall 
clear  and  unchanged,  we  generally  find  it  cloudy  w^ith 
whitish-yellow  spots  of  beginning  necrosis,  or  we  may 
find  even  early  the  entire  wall  seminecrotic.  Even  in 
these  cases  w^e  are  often  surprised  at  the  reparative 
possibilities  after  drainage  is  instituted. 

The  tendons  themselves  are  swollen,  but  retain  their 
glistening  synovial  covering  for  some  time.  At  the 
wrist,  however,  the  tendons  show  the  result  of  com- 
pression by  the  non-distensible  anterior  annular  liga- 
ment being  pale  and  compressed;  this  is  accentuated 
by  the  swelling  w^iich  has  occurred  both  above  and 
below  the  ligament.  If  the  case  has  been  left  un- 
treated for  too  long  a  time,  the  tendons  lose  their 
glossy  covering  and,  becoming  necrotic,  are  extruded, 
looking  like  grayish  strings  of  connective  tissue. 

While  the  entire  hand  partakes  of  the  edema,  it  is 
in  the  finger  involved  that  the  most  extensive  and 
persistent  changes  occur.     Especially  in  the  neglected 


198  PATHOLOGY  OF  TENDON  SHEATH 

cases  do  we  see  a  most  extensive  exudation  of  inflam- 
matory elements  which  persist  for  weeks  after  the  acute 
process  has  subsided;  this  is  followed  by  an  atrophy 
of  the  entire  finger,  ankylosis  of  joints  and  impaired 
nerve  function,  which  aids  materially  in  preventing  a 
proper  use  of  the  finger  even  if  the  tendon  is  not 
destroyed.  The  adhesions  between  the  sheath  and  the 
tendon  combined  with  these  serious  sequelae  make  an 
almost  hopeless  prognosis  as  to  function  in  the  neglected 
cases. 

If  the  ulnar  bursa  has  been  involved,  the  ultimate 
result  is  the  characteristic  claw-hand. 

THE  FASCIAL  SPACE  ABSCESSES 

In  discussing  the  essential  pathology  it  should  be 
remembered  that  we  are  restricting  ourselves  strictly 
to  that  phase  of  the  subject  having  a  relation  to  the 
anatomical  and  experimental  studies  preceding.  The 
pathology  of  acute  abscess  formation  in  connective 
tissue  is  too  well  known  to  merit  discussion  here. 
Moreover,  to  do  more  than  mention  the  arthritis  in 
the  wrist,  the  osteomyelitis  of  the  metacarpals,  and  the 
destruction  of  tissue  and  fistulous  sequelse  would  be 
out  of  place,  since  these  will  be  discussed  in  the  chap- 
ters dealing  especially  with  these  subjects.  We  should, 
however,  draw  attention  to  certain  consequences  of 
suppuration  in  the  individual  spaces. 

Let  us  ask  ourselves  what  would  be  the  after-results 
of  infection  of  the  middle  palmar  space  alone,  the 
tendon  sheath  not  being  opened.  We  shall  divide 
them  into  primary  and  secondary;  and  under  the 
caption  of  primary,  attention  should  be  drawn  to  the 
fact  that  the  scar  tissue  following  such  a  process  would 
involve  particularly  the  tendons  of  the  middle  and  ring 
fingers,  with  the  lumbrical  muscles  of  the  middle,  ring. 


THE  rjs( :/.//.  s />./(./■:  .mscEssKs  i<m> 

•and  lilllc  lingers.  (\)ns('(|iicii(ly,  il  is  in  these  rmi;ers 
(hat  we  would  expect  to  liiul  the  most  persistent 
adhesions  and  contraction;  and  it  is  in  conse(|uence 
of  the  disturbed  circulation  in  tlie  bloodvessels  going 
to  these  fingers  that  long  persisting  edema  and  nutri- 
tional changes  occur,  augmented  somewhat,  probably, 
by  impaired  nerve  supply. 

Secondary  sequelae  are  noted  in  the  associated 
edema  and  changes  in  the  index  finger  and  the  thumb, 
and  while  these  are  severe,  they  are  not  of  such  high 
grade  as  in  others.  These  changes  are  most  marked 
in  the  index  finger,  and  are  due  to  the  juxtaposition 
of  the  tendons  and  the  intimate  relation  of  'the  circu- 
lation. Moreover,  the  ulnar  bursa,  with  its  contained 
tendons,  is  adjacent  to  the  area  of  infection;  conse- 
quently, there  is  the  probability  of  a  low^  grade  of 
inflammation  within.  Again,  the  corollation  of  move- 
ment between  the  tendons  determines  approximately 
the  same  position  for  the  index  finger  as  the  others. 
This  constant  position,  associated  with  an  effusion 
into  the  joints,  leads  to  adhesions  of  the  articular 
surfaces  in  all  the  fingers,  the  thumb  least  of  all,  since 
the  tendon  of  the  thumb  is  well  separated  from  the 
site  of  infection.  Should  the  process  extend  to  the 
thenar  area,  the  index  finger  would  then  be  in  the  same 
condition  as  the  other  fingers.  On  the  other  hand,  if 
the  infection  were  primary  in  the  thenar  space,  the 
most  disastrous  changes  would  ensue  in  that  finger, 
while  the  other  three  fingers  would  suffer  only  the 
secondary  changes,  but  fortunately  not  so  severe 
as  the  secondary  changes  were  in  the  thenar  space 
when  associated  with  palmar  infection.  This  is  owing 
not  alone  to  the  comparative  size  and  complexity  of 
the  areas,  but  also  to  the  fact  that  thenar  abscesses 
are  sooner  recognized  and  drained  more  perfectly; 
consequently  the  process  is  not  so  disastrous. 


200  PATHOLOGY  OF  TENDON  SHEATH 

Should  the  subaponeurotic  space  be  involved  pri- 
marily, or  by  an  extension  from  the  palmar  space, 
secondary  adhesions  take  place,  and  the  whole  sheet 
becomes  more  or  less  immobile  as  a  consequence  of 
the  involvement  of  all  the  extensor  communis  tendons. 
Should  proper  treatment  be  resorted  to  even  after  a 
number  of  days,  all  of  these  changes  will  disappear 
and  a  perfectly  functionating  hand  be  assured. 


ch;apter  XIV 

THE  SYMPTOMS,  SIGNS,  AND  DIAGNOSIS  OF 

TENOSYNOVITIS  AND  FASCIAL  SPACE 

ABSCESSES 

THE  SYMPTOMS,  SIGNS,  AND  DIAGNOSIS  OF  ACUTE 
TENOSYNOVITIS 

To  diagnosticate  the  onset  of  involvement  of  the 
tendon  sheaths  is  one  of  the  most  difficult  problems 
in  surgery;  and  yet  withal  one  of  the  most  important. 
I  know  of  no  place  where  calm  judgment  is  more  re- 
quired, since  the  symptoms  and  signs  are  all  of  degree. 
It  must  be  said,  however,  that  more  extensive  expe- 
rience has  taught  me  that  it  is  generally  better  to 
err  by  making  an  unnecessary  incision  than  by  failing 
to  operate  where  it  is  needed. 

The  three  cardinal  symptoms  and  signs  are: 

1 .  Excessive  tenderness  over  the  course  of  the  sheath, 
limited  to  the  sheath.  This  symptom  is  by  all  odds 
the  most  important. 

2.  Flexion  of  the  finger. 

3.  Excruciating  pain  on  extending  the  finger,  most 
marked  at  the  proximal  end. 

These  symptoms  are  seen  to  be  only  a  difference  in 
degree  from  those  found  in  any  infection  of  the  hand, 
but  when  sought  for  in  an  intelligent  manner  there  is 
not  much  difficulty  in  differentiating  the  conditions. 

A  patient  applies  to  the  ph^'sician  with  what  is 
evidently  a  serious  infection.  If  there  has  been  a 
crushing  injury,  the  probability  of  an  infected  tendon 
sheath  is  great;  on  the  other  hand,  it  frequently  arises 
from  simple  cuts,  as,  for  instance,  a  slight  laceration 


202     SYMPTOMS,  SIGNS,  DIAGNOSIS  OF  TENOSYNOVITIS 

from  a  tin  can  or  from  the  prick  of  a  needle.    The  pain 
has  increased  in  severity  after  a  day  or  two.     The  sys- 
temic symptoms  of  infection   may   be   present.      The 
finger  and  the  corresponding  side  of  the  hand  at  least 
are  edematous.     In  addition  to  the  tumefaction  in  the 
infected  finger  the  adjacent  digits  are  swollen.     The 
back   of   the   hand    particularly   is   edematous.      The 
whole  hand  is  slightly  tender  to  superficial  palpation. 
The  fingers  are  all  slightly  flexed.     Now,   how  shall 
the  differential  diagnosis  be  made?     Press  deeply  and 
firmly  in  all  parts  of  the  hand  and  fingers;  the  patient 
will  volunteer  the  information  that  all  points  hurt;  but 
if   the    tendon    sheath    is   involved,  pressure  upon    it 
throughout  its   course   causes   an   immediate  and   in- 
voluntary  expression   of   pain,    and   while   before   the 
patient   has   allowed   his   hand   to   remain   passive   in 
yours,  he  will  now  attempt  to  withdraw  it  voluntarily, 
and  there  is  no  doubt  in  your  mind  of  the  exquisite 
tenderness  over  this  area.     If  this  tenderness  is  out- 
lined by  the  extent  of  the  sheath,  your  diagnosis  is 
nearly  made.    As  a  matter  of  fact,  the  greatest  tender- 
ness is  generally  complained  of  on  deep  pressure  at 
the  proximal  end  of  the  finger  sheaths  in  the  palm  of 
the  hand,  just  over  the  metacarpophalangeal  articu- 
lation.     I  have  seen  a  lacerated  wound  on  the  back 
of  the  finger,  which  was  inflamed  and  naturally  tender, 
show  much  less  sensitiveness  than  the  infected  sheath 
on  the  opposite  side  of  the  finger  where  there  was  no 
injury.      Now  make  passive  extension  of  the   finger, 
and  the  patient  immediately  complains  of  severe  pain 
along  the  tendon  sheath,  very  often  again  most  marked 
at  the  site  of  the  metacarpophalangeal   articulation. 
This  is  a  valuable  symptom.    The  flexion  of  the  fingers 
is  of  less  importance  and  is  probably  due  to  several 
factors — the    arthritis    in    the    finger- joints,    possibly 
irritation  of  the  adjacent  filaments  of  the  median  or 


./CUT/':  ■/■/■:s()sy.\()iiT/s  20;; 

uliiai'  iuT\c,  and  <i.u<iiii,  po^^ihly  hccaiisc  it  k-sscns  the 
(cnsioii  upon  the  Icndoii.  Ihc  lii)iL;cr  is  iLicncrally  licid 
rigid  in  that  position  and  a  dilTcRMU'c  is  rcadil\'  seen 
Ix'lwccn  till'  sinipk'  ik-xioii  occurring  in  the  adjacent 
swollen  lingers  and  the  rigid  llexion  of  the  infeeled 
linger.  So  marked  is  this  that  often  one  is  akie  to 
diagnosticate  an  extension  into  the  j)alniar  sheath,  for 
instance,  from  the  little  finger  sheath,  since  the  char- 
acter of  the  flexion  changes  in  that  case  at  once  in  the 
fingers  supplied  by  these  tendons  which  pass  through 
this  common  sheath.  Mauclaire  has  described  a  claw- 
hand  position,  but  I  have  not  found  it  to  be  character- 
istic of  acute  inflammation,  but  to  be  rather  the  evi- 
dence of  an  old  chronic  untreated  tenosynovitis. 

There  are  two  clinical  types  to  be  differentiated. 
First,  that  variety  in  which  the  infection  is  a  local  one, 
generally  of  staphylococcic  origin,  commonly  following 
lacerated  w^ounds.  Here  we  have  a  local  infection 
beginning  slowly;  plastic  adhesions  may  be  present, 
limiting  the  infection  to  a  particular  part.  There  is  a 
little  general  reaction,  but  the  local  evidences  of  inflam- 
mation are  marked.  A  second  type  is  that  in  which 
the  injury  is  generally  a  slight  one,  a  pin  prick  or  an 
insignificant  cut.  It  is  generally  of  streptococcic  origin. 
The  infection  is  carried  to  the  sheath  by  lymphatics. 
The  pain  is  severe,  and  within  a  few  hours  the  finger 
is  greatly  swollen,  red,  and  exquisitely  tender.  The 
evidences  of  toxemia  are  present  early,  but  the  red 
lines  running  up  the  arm,  indicative  of  a  lymphangitis, 
are  absent,  although  they  may  have  been  present  earh- 
(see  Case  XVIII).  This  type,  not  having  a  tendency 
to  plastic  adhesions,  spreads  rapidly  throughout  the 
entire  communicating  system  of  sheaths.  This  is  dis- 
tended with  a  fluid,  at  first  onh-  cloud>-,  but  raj^idh 
becoming  purulent,  and  on  examination  we  find  thick 
pus    with    fragmented    nuclei,    due    probabK'    to    the 


204    SYMPTOMS,  SIGNS,  DIAGNOSIS  OF  TENOSYNOVITIS 

virulent  toxins,  and  here  and  there  streptococci.  This 
type  is  prone  to  produce  early  rupture  and  extension 
into  the  connective-tissue  spaces. 

The  spontaneous  pain,  which  was  at  first  severe, 
grows  less  as  the  edema  develops,  and  may  delude  the 
surgeon  into  believing  that  the  process  is  subsiding. 
The  arm  seems  to  "fall  asleep,"  as  the  patient  expresses 
it.  Paresthesias,  with  creeping  and  itching  sensations, 
may  be  present,  and  especially  after  rupture  of  the 
sheath  the  tenderness  may  subside  to  a  considerable 
degree,  leading  the  surgeon  to  an  early  erroneous  con- 
clusion. 


Symptoms,  Signs,  and  Diagnosis  of  Extensions  from  Infections 
Beginning  in  the  Little  Finger 

An  infection  of  the  sheath  of  the  tendon  in  the  little 
finger  may  be  localized  to  the  finger.  Extensions  to 
other  areas  are  probable,  however  (Fig.  67).  The  fol- 
lowing are  the  most  common:  (i)  The  ulnar  bursa; 
(2)  the  radial  bursa;  (3)  the  forearm;  (4)  fascial  spaces 
in  the  hand,  {a)  middle  palmar  space,  {h)  lumbrical 
space;  (5)  osseous  involvement,  middle  phalanx;  (6) 
joints,  proximal  interphalangeal,  wrist;  (7)  rupture  to 
the  surface. 

Extension  to  the  Ulnar  Bursa. — In  the  fulmina- 
ting type,  where  the  opening  between  the  ulnar  bursa 
and  the  sheath  in  the  little  finger  is  present,  the  infec- 
tion extends  rapidly  throughout  the  hand.  It  should 
be  noted  here  that  the  frequency  of  extension  from  the 
one  to  the  other  is  greater  than  the  anatomical  opening 
would  explain ;  we  are  therefore  led  to  conclude  that  the 
opening  is  present  much  more  frequently  than  is  stated, 
or  there  is  some  other  method  of  extension,  possibly 
by  the  lymphatics. 

This   extension   is   often    difficult    to   diagnosticate. 


INFECTIONS  BEGINNING  IN  TlIK  lATTLE  FINGER     205 

It  is  inarkid  h\  the  (1(\  rlopniciit  of  ((Iciiia  in  the  liand, 
especially  iii)on  the  (lorsiiiii.  A  general  fulness  in  the 
palm  is  foiiiul,  but  the  palmar  concavity  is  still  present. 

Fig.  67 


//»(■  mid  jiiiiit. 

u'l'-tinsiic  xpace  in  web 
mild  lumhncal  muscle. 


•face  throwjh  pdhniir  fit.scia. 
To  middle  palmar  space. 


Exveptioualbj  to  ivrist  Joint. 


~  Under  flexor  profundus. 


Schematic  drawing  showing  the  various  probable  extensions  from  an 
infection  of  the  tendon  sheath  of  the  Httle  finger. 


On  the  flexor  surface  the  greatest  swelling  is  just 
proximal  to  the  annular  ligament.  This  is  not  neces- 
sarily due  to  the  rupture  of  the  sheath  here,  but  to  the 
looseness  of  the  tissues  which  permits  of  distention. 


206     SYMPTOMS,  SIGNS,  DIAGNOSIS  OF  TENOSYNOVITIS 

This  swelling  is  accentuated  by  contrast  with  the  non- 
distensible  annular  ligament  distal  to  it.  The  swelling 
in  the  palm  occurs  at  the  same  time,  but  is  not  so  con- 
spicuous, owing  to  the  palmar  fascia.  This  also  diffuses 
the  swelling  so  that  it  is  not  accurately  limited  by  the 
outline  of  the  ulnar  bursa.  Moreover,  the  surrounding 
edema  tends  to  confuse  the  picture.  In  relation  to 
this  Forssell  states: 

''One  very  seldom  finds  in  acute  infections  of  the 
bursse  so  great  a  collection  of  pus  within  the  latter 
as  to  cause  a  purely  mechanical  swelling  of  such  extent 
that  one  can  easily  see  it  from  the  outside.  The  wall 
of  the  bursa,  before  an  extensive  formation  of  exudate, 
is  necrotic  and  has  usually  permitted  the  accumulation 
to  escape  into  the  surrounding  connective-tissue 
spaces." 

As  to  fluctuation,  Mauclaire  says:  "Fluctuation  is 
almost  the  rule.  One  can  easily  notice  it  by  placing 
the  fingers  above  and  below  the  annular  ligament." 
While  I  agree  that  a  sense  of  fluctuation  can  be  noted 
by  this  maneuver,  yet  the  edema  and  swelling  is  of 
such  a  character  that  I  cannot  attach  the  significance 
to  it  that  is  given  by  Mauclaire.  One  should  never 
wait  for  this  symptom  before  operating.  In  chronic 
tenosynovitis,  such  as  tuberculous  infection,  the  symp- 
tom is  of  undoubted  value. 

The  most  conspicuous  and  valuable  sign  is  the  ex- 
tension of  the  exquisite  tenderness  to  the  area  involved. 
It  should  be  remembered  that  this  is  absent  after  a 
few  days.  The  wrist  becomes  fixed,  the  thumb  shows 
tenderness  to  pressure,  and  particularly  on  passive 
movement  is  the  sensitiveness  noted.  It  is  seen  readily 
of  how  much  importance  this  latter  symptom  is  in 
diagnosticating  an  extension  to  the  ulnar  bursa  from  the 
little  finger.  We  note  that  while  at  first  the  symptoms 
are  limited  to  the  little  finger  and  slight  changes  in  the 


iXFKCT/oxs  /i/-:(;/\.\/.\(;  /.v  '////■:  i.ittli:  iim.hr    i'o7 

I'iiiU  riiiiicr  hccaiisc  ol  its  jii\la|)()sil ion,  all  at  once  the 
lliuml)  ])ci;ins  to  show  the  characteristic  sij^iis  of  con- 
tiactiire  and  leiideiiicss,  wJiilc  the  iiuiex  and  middle 
finLicrs  I'einain  unchaiiiied  except  lor  the  increase  of 
pain  (Ml  i)assi\e  extension  exj^lained  above.  This  sen- 
sitiveness of  the  thumb  may  be  due  to  either  the 
juxtaposition  of  the  sacs  or  to  a  real  extension  into 
its  sheath. 

At  first  there  may  be  a  diffuse  redness  of  the  palm 
and  dorsum,  but  it  rapidly  gives  place  to  a  whitish  or 
even  cyanotic  hue.  Above  the  wrist,  however,  the 
tissue  generally  takes  on  a  marked  red  color,  which 
later  becomes  violaceous.  The  temperature  and  ])ulse 
may  not  be  of  any  diagnostic  importance.  Ordinarily, 
after  the  infection  has  lasted  a  few  days  and  the  walling- 
off  process  has  begun,  the  temperature  is  that  of  the 
local  accumulation  of  pus  and  varies  with  the  freedom  of 
drainage.  In  the  first  few  days,  however,  the  systemic 
absorption  bears  no  relation  to  the  abscess  formation 
and  cannot  be  relied  upon  for  diagnostic  purposes. 

Extension  to  the  Radial  Bursa. — This  is  diag- 
nosticated as  following  an  ulnar  bursitis  by  the  in- 
creased swelling  and  tenderness  in  the  thenar  eminence 
and  along  the  sheath  with  the  associated  symptoms 
described  above.  The  tumefaction  of  the  thenar  area 
is  not  that  of  abscess  in  the  thenar  space.  Forssell 
states  that  this  extension  occurred  in  6  out  of  29  cases 
coming  under  his  observation — average  age,  hft\-  to 
hft>-eight  years;  23  cases  remained  confined  to  the 
ulnar  bursa — average  age,  thirty-six  to  thirt\-nine 
years.  In  my  own  experience  the  percentage  of  ex- 
tension is  greater. 

Extension  to  the  Forearm. — B>  this  we  mean  a 
rupture  from  the  proximal  end  of  the  sheath  and  an 
extension  along  the  connective-tissue  spaces,  or  rather 
the  intermuscular  spaces.     As  I  ha^T  already'  pointed 


208     SYMPTOMS,  SIGNS,  DIAGNOSIS  OF  TENOSYNOVITIS 

out,  the  pus  passes  between  the  pronator  quadratus  and 
the  flexor  profundus  to  the  area  between  the  latter 
and  the  interosseous  membrane,  and  at  about  the 
middle  of  the  area  it  passes  more  superficially  and  to 
the  ulnar  side  along  the  ulnar  artery  and  nerve.  I 
have  had  opportunity  to  verify  this  area  of  extension 
many  times  in  cases  I  have  operated  upon,  and  have 
also  seen  it  in  one  fatal  case  I  had  an  opportunity  to 
dissect  (Case  XXII).  This  extension  is  characterized 
by  a  brawny  induration  that  should  not  be  confused 
with  the  softness  of  an  edema.  No  fluctuation  should 
be  expected,  since  the  accumulation  lies  too  deeply. 
This  extension  is  marked  also  by  the  loss  of  the  rela- 
tive swelling  immediately  above  the  annular  ligament 
due  to  the  distended  upper  end  of  the  sheath.  This 
swelling  is  not  any  less,  but  that  of  the  arm  is  greater. 
The  tenderness  may  become  less,  so  it  cannot  be 
depended  upon  as  a  symptom.  The  redness  is  generally 
greater,  and  spontaneous  pain,  while  at  first  marked, 
rapidly  subsides  (see  Chapter  XXVI). 

At  this  time  some  pus  may  accumulate  subcu- 
taneously  above  the  wrist,  due  to  lymphangitis,  and 
lead  to  the  supposition  that  there  is  no  pus  under  the 
tendons,  so  that  valuable  time  is  lost. 

Extension  to  the  Lumbrical  and  Palmar  Spaces. 
— One  of  the  commonest  sites  of  extension  is  into  the 
lumbrical  and  palmar  spaces.  The  involvement  of 
the  adjacent  lumbrical  space  occurs  so  frequently  as 
to  keep  one  continually  on  his  guard,  since  from  this 
involvement  of  the  tendon  of  the  adjacent  finger  or 
palm  occurs  very  easily.  It  is  characterized  by  ten- 
derness, swelling,  and  pain  at  the  site.  The  tissue 
between  the  fingers  on  the  dorsum  of  the  corresponding 
web  is  generally  swollen  and  red;  the  side  of  the  finger 
adjacent  to  the  infected  finger  is  often  red  and  tender. 


EXTENSIONS  FROM  INFECTJOAS  L\   THE  FINGERS     209 

It  begins  U)  swell  slightly,  and  b>'  exte-nsioii  the  tfiulon 
sheath  of  that  finger  often  becomes  involved  with  the 
characteristic  symptoms  and  signs.  In  iii\ oK cment 
of  the  lumbrical  space  alone,  the  swelling  of  the  area 
involved  is  marked.  The  middle  palmar  space  is  most 
commonly  involved,  either  by  extension  along  the 
lumbrical  space  or  from  rupture  of  the  ulnar  bursa 
which  lies  in  juxtaposition.  The  thenar  space  is  never 
primarily  involved  in  the  little  finger  infections.  In- 
volvement of  the  middle  palmar  space  is  characterized 
by  a  slight  bulging  of  the  palm  replacing  the  normal 
concavity.  The  symptoms  and  signs  of  this  complica- 
tion, as  well  as  those  observed  in  osseous  and  joint 
involvement,  will  be  discussed  in  the  subsequent  pages 
(see  Chapter  XXVIII).  Also  mention  should  be  made 
of  the  frequency  of  rupture  of  the  sheath  through  the 
palm  to  the  surface  at  the  proximal  end  of  the  finger 
sheath  in  neglected  cases. 

Fig.  68 


(  To   ejiiijlii/seul    line 
l<     of  middle  jdidlaiix 
(did  jdiiil. 


Ti)  /((.<(■/'((/  sjKifi's  ahiial 

■ji\-\     "■'^^'  '""'  around  (he 
y{  (    lumbrical  muscles. 

iJij)  I  Thromjh  /jalmar  fascia 


N 


to  surface. 
To  thenar  space. 


Schematic  drawing  showing  probable  extensions  from  an  infection  of  the 
tendon  sheath  of  the  index  finger. 


Symptoms,  Signs,  and  Diagnosis  of  Extensions  from  Infections 
Beginning  in  the  Index,  Middle,  and  Ring  Fingers 


Involvement  of  the  index,  middle,  and  ring  lingers 
presents  the  same  signs  as  the  little  finger.     The  only 


210     SYMPTOMS,  SIGNS,  DIAGNOSIS  OF  TENOSYNOVITIS 

difference  is  that  here  the  paths  of  extension  are 
different.  Besides  the  extension  to  the  surface  at  the 
proximal  end,  involvement  of  the  middle  phalanx,  and 
the  proximal  interphalangeal  joint,  the  finger  may  show 
extension  to  the  lumbrical  space  on  either  side,  and 

Fig.  69 


L   f  To   epiphyseal   line 

-J  ;    of  middle  phalanx, 

and  to  joint. 


To  fascial  spaces  about 
toeb  and  around  the 
lumbrical  muscles. 
I  Through  palmar  fascia 
[    to  surface. 

f  To  middle  palmar  space; 
I    exceptionally,  the  thenar  space. 


Schematic  drawing    showing   probable  extensions    from    infection    of    the 
tendon  sheath  of  the  middle  finger. 


Fig.  70 


To  epiphi/seal  line 
of  middle  phalanx, 
and  to  joiiit. 


To  fascial  .spaces  about 
web  and  around  the, 
lumbrical  muscles. 
f  ThroHijh  palmar  fn.scia 

\  "1 

\     P^  To  middle  palmar  space. 

Schematic    drawing    showing    probable    extensions    from    the   infection   of 
the  tendon  sheath  of  the  ring  finger. 

from  here  the  adjacent  tendon  may  be  involved  (see 
Case  VII).  The  fingers  differ  somewhat  in  the  method 
of  their  extension  into  the  palm,  as  will  be  seen 
by  noting  the  accompanying  drawings  (Figs.  68,  69, 
and  70).     The  middle  and  ring  fingers  drain  into  the 


i':XTEASIO\S  I  ROM   IXIKCTIO.XS  J  .\    THE  ILXCERS     211 

niiddk'    i)almar   space,   and    tlic   index    fuii^cr    into    the 
thenar  space. 

As  ilkistratiiis;  the  extension  from  the  indc-x  tinker 
into  the  thi-nar  space,  with  no  in\'ol\cnu'nt  ol  tlie  middle 
l)ahiuir  space,  I  record  the  case  of  Miss  M.,  seen  with 
Dr.  I^esle>'  at  the  Post-Ciraduate  Hospital.  The  proh- 
abihty  of  this  extension  was  p(Mnted  out  b)'  nnself 
experimentally  some  time  previous  U)  the  opportunity 
to  obser\e  a  clinical  case  provin.i;'  the  assumption. 
Fii;.    71    sho\\s  such  a   con(h'tion. 

Fi(..  71 


Schematic  drawing  made  from  a  dissection  of  a  hand  in  which  the  injec- 
tion was  made  along  the  tendon  sheath  of  the  index  finger.  Mass  filled 
thenar  space  and  extended  along  the  lumbrical  muscle. 

Case  XI.  Seen  in  consultation  with  Dr.  F.  A. 
Besley  at   the   P()st-( '.radiiate  H()si)ital.  October,   1906. 

///5/^)/'V.  Patient  stated  that  t  wentx-ioiir  hours 
bt'fore  she  had  run  a  needle  in  the  distal  phalanx  of 
the  index  fmger  of  the  right  hand.      Inside  ot  .se\en  or 


212     SYMPTOMS,  SIGNS,  DIAGNOSIS  OF  TENOSYNOVITIS 

eight  hours  the  pain  became  severe  and  she  arrived 
at  the  hospital  complaining  of  excessive  pain  and  ten- 
derness. 

Examination. — Patient's  temperature,  102.5°;  pulse, 
100.  Index  finger  seemed  to  be  slightly  swollen.  Ten- 
derness was  present  over  the  entire  finger  and  the  lower 
portion  of  the  hand  on  the  radial  side  without  localiza- 
tion at  any  point.  The  glands  in  the  axilla  were 
swollen,  those  in  the  elbow  not  involved.  No  lymphatic 
lines  seen. 

Treatment.— A  diagnosis  of  lymphatic  infection,  pos- 
sibly tenosynovitis,  was  made  and  hot  boric  dressings 
applied. 

The  next  morning  the  temperature  had  fallen 
markedly  and  the  patient  insisted  on  leaving  the 
hospital.  She  returned  in  two  days  with  all  the  evi- 
dences of  acute  systemic  infection — temperature,  102°; 
headache  and  sleeplessness.  Locally  the  finger  pre- 
sented about  the  same  appearance  as  when  seen  two 
days  before,  except  that  there  was  a  slight  increase 
in  swelling  and  the  thenar  space  from  the  adduction 
crease  in  the  thumb  seemed  to  be  ballooned  out  from 
the  remainder  of  the  hand.  The  concavity  of  the 
palm  was  still  present. 

Diagnosis  of  previous  tenosynovitis  in  the  index 
tendon  sheath,  with  rupture  at  its  proximal  end  and 
involvement  of  the  thenar  space,  was  made. 

On  operation  pus  was  found  to  be  present;  there  was 
a  very  large  accumulation  in  the  thenar  space,  which 
was  drained  by  through-and-through  drainage  from  the 
palm  to  the  dorsum  between  the  metacarpal  bones  of 
the  index  finger  and  the  thurpb.  The  tendon  sheath 
of  the  index  finger  was  opened  throughout  its  extent. 

Course. — Patient's  temperature  rapidly  subsided  and 
in  two  or  three  days  was  normal  or  99°.  Infection  of 
the  thenar  space  had  entirely  subsided  at  the  end  of 


EXTENSIONS   FROM    IMKCTIOXS    l\   k.lDI.II.   HI  MS./     lMo 

si'\rii  (la\s,  and  ihc  wounds  healed  proiii])!!}.  i  he 
()j)eniiii;  \n  the  leiidoii  sheath  ol  the  index  hiiiitT, 
however,  was  present  lor  four  weeks,  necessitating 
repeated  ch'essings. 

Result. — -Recovery  witli  all  lunclicjns  except  llexi(jn 
of  the  distal  phalanges  of  the  index  finger. 

Fig.  72 


Under  flexor  profundus. 


Schematic   drawing    showing    probable    extensions    from    infection   of   the 
tendon  sheath  of  the  thumb.    (Flexor  longus  pollicis.) 


Symptoms,  Signs,  and  Diagnosis  of  Extensions  from  Infection 
Beginning  in  the  Radial  Bursa 


The  gravity  of  tenosynovitis  of  the  flexor  longus 
pollicis  of  the  thumb  has  long  been  recognized.  The 
symptoms  and  signs  common  to  the  other  fingers  are 


214     SYMPTOMS,  SIGNS,  DIAGNOSIS  OF  TENOSYNOriTIS 

loiind  here.  To  diagnosticate  the  extension  into  the 
radial  bursa  and  then  to  the  ulnar  bursa  is  more 
difficult  (Fig.  72).  Let  us  suppose  the  thumb  has  been 
the  seat  of  the  primary  infection.  This  member  is  very 
painful,  the  index  finger  slightly  sensitive,  and  the 
other  three  fingers  hardly  at  all.  After  a  time,  if  the 
infection  spreads  throughout  the  sheath,  all  the  fingers 
become  more  painful  to  passive  extension,  and  should 
the  infection  pass  over  into  the  ulnar  sheath  all  the 
fingers  become  flexed  and  the  pain  severe  upon  exten- 
sion of  the  tendons,  most  marked,  however,  in  the 
little  finger.  In  other  words,  it  assumes  the  character 
of  an  ulnar  sheath  infection.  The  tenderness  over  the 
sheath  is  not  always  so  marked  in  secondary  involve- 
ment, however,  due  possibly  to  the  previously  developed 
edema.  I  recall  one  case  where  the  only  marked  ten- 
derness was  at  the  base  of  the  little  finger.  Here, 
however,  owing  to  this  tenderness,  which  was  not  present 
at  the  base  of  the  other  fingers,  a  diagnosis  of  involve- 
ment of  the  ulnar  bursa  was  correctly  made.  Forssell's 
statistics  show  that  23  out  of  27  cases  of  radial  bursitis 
extended  to  the  ulnar  bursa — average  age,  forty-three 
years;  the  4  that  remained  confined  to  the  radial  bursa 
averaged  thirty-seven  and  one-half  years  of  age.  It 
cannot  be  emphasized  too  strongly  that  in  the  early 
state  of  secondary  involvement  of  the  ulnar  bursa  there 
is  no  marked  swelling  upon  the  palmar  surface  and  that 
there  is  no  special  tumefaction  over  the  ulnar  bursa. 

One  fact  may  confuse  the  surgeon  in  that  the  ten- 
derness over  the  radial  bursa  may  be  absent.  Not 
only  that,  but  upon  operation  no  macroscopic  pus  may 
be  found  in  the  middle  part  of  the  sheath.  By  careful 
extension  of  the  incision  and  pressure  upon  the  two 
ends  pus  may  be  brought  into  the  wound. 

The  extension  of  the  infection  into  radial  bursa  is 
generally  accompanied  by  a  swelling  above  the  anterior 


r.isci  II.  sr.n:i:  .insci-ssi-s  I'l.') 

.iiiiiiil.ir  li;^,iiii(iil  ,  ]\\^\  A--  111  ulnar  Inn's. i  inlcclion.  Il 
ni.i\  I'nplnrc  iVoni  here  intd  the  lissiics  ol  the  lorcirni, 
and  1  hen  I  he  pns  lies  under  (he  llcxor  prol  nndu^  Icndoiis, 
as  i)rc\i()iisly  dcsciihcd  in  discussint;  rupt  urc  ol  ihc  ulnar 
bursa  (sec  jiai^c'  I4(j  and  ("liaptcr  XX\'I  loi- coniijlctc 
discussion  of  lOrcarni  exlcnsions). 

Tlic  diagnosis  of  inxolvcnicut  ol    (he  wrist -joint   will 
he  discussed  in  ('hai)ter  XXX'l. 


Tin-:  SYMI'TOMS,  SIONS,  AND   DIAGNOSIS  OF  FASCIAL 
SPACE  ABSCESSES 

The  well-defined  spaces  I  have  described  as  being 
present  in  the  hand  may  be  infected  primarily  or  sec- 
ondarily to  a  tendon  sheath  infection.  In  either  case 
the  symptoms  and  signs  are  the  same  except  that  the 
diagnosis  of  the  location  of  the  pus  is  simplified  when 
we  have  had  a  certain  finger  sheath  involvx'd,  as  has 
already  been  pointed  out.  Let  us  discuss  the  question, 
however,  as  if  we  were  dealing  with  one  or  more  of  the 
spaces  without  relation  to  tenosynovitis.  The  student 
will  have  no  difficulty  in  combining  or  differentiating 
the  two  pictures  if  they  are  present  in  an  individual 
case,  and  the  differentiation  must  be  made,  since  in 
draining  a  tendon  sheath  we  do  not  drain  a  fascial 
space,  nor  vice  versa.  Each  must  be  treated  separately, 
even  if  in  a  given  case  the  two  infections  are  combined. 

The  symptoms  and  signs  may  be  divided  into  local 
and  general.  The  general  evidences  of  this  variety  oi 
infection  do  not  differ  at  all  from  those  seen  elsewhere. 
The  temperature  often  reaches  103°  to  104°,  and  the 
restless  tossing  of  the  patient,  the  sleepless  nights,  the 
wandering  eye,  the  sweaty  brow,  and  the  flushed 
cheek  all  demonstrate  the  absorption  of  the  toxins, 
bound  in  closed  spaces,  with  no  means  of  exit. 

Locally,   one  elicits   particular   pain    limited    to   the 


216     SYMPTOMS,  SIGNS,  DIAGNOSIS  OF  TENOSYNOVITIS 

area  involved.  This  localization  of  the  pain  is  not  so 
definite,  however,  as  that  noted  in  the  synovial  sheath 
infection,  particularly  in  those  patients  in  whom  the 
mental  equilibrium  is  disturbed  as  a  result  of  suffering 
and  septic  intoxication.  After  a  number  of  days  the 
tenderness  and  pain  grow  less  severe  owing  to  the 
edema  with  pressure  on  the  nerves.  Unfortunately, 
the  brawny  induration  so  helpful  in  diagnosticating 
subcutaneous  accumulations  of  pus  cannot  be  definitely 
elicited  upon  the  palmar  surface,  owing  to  the  palmar 
fascia  and  its  general  rigidity.  Upon  the  dorsal  surface, 
however,  the  induration  and  localized  tenderness  will 
aid  us  materially  in  distinguishing  between  the  doughy, 
pitting  edema  which  is  always  present  and  an  accumu- 
lation of  pus,  long  before  fluctuation  gives  its  tardy 
evidence.  The  position  of  the  fingers  is  worth  noting. 
Incident  to  any  inflammatory  process  about  the  palm  of 
the  hand,  with  its  consequent  edema,  the  fingers  tend  to 
become  flexed;  here,  however,  the  flexion  of  the  fingers 
is  neither  so  marked  nor  so  rigid  as  in  synovial  sheath 
infection. 


The  Middle  Palmar  and  Thenar  Spaces 

If  the  middle  palmar  space  be  involved,  we  are  often 
aided  in  making  the  diagnosis  by  the  site  of  the  primary 
injury.  Since  in  the  chapter  upon  pathogenesis 
(Chapter  XI)  the  routes  of  extension  from  various 
fingers  and  parts  of  the  hand  were  pointed  out,  it  is 
not  necessary  to  go  into  detail  upon  this  subject  again, 
although  an  example  may  be  given.  For  instance, 
in  Case  VIII  the  palmar  surface  was  evidently  in- 
volved. The  fistulous  tract  on  the  dorsum  opened 
over  the  metacarpal  bone  of  the  hypothenar  area 
dorsally;  but  with  the  facts  in  mind  that  the  meta- 
carpal bone  of  the  middle  finger  was  fractured  and 


THE   MIDDLE   E.IEM.IR   .l\D   'E//E\.lk  S/'./CES        _' I  7 

inl\'c(c(l,  and  also  that  pus  in  the  ^uhapoiiciii'otic  space 
^^()lll(I  lend  to  |)oinl  at  the  side,  a  diaiinosis  of  pus  in 
the  middle  i)alniar  space  rather  than  the  hypothenar 
was  made.  Drainage  of  this  space  was  instituted,  and 
the  immediate  fall  of  the  tcmj)erature,  with  rajiid 
convalescence,  substantiated  the  diagnosis.  Tender- 
ness most  marked  over  this  area,  swelling  of  the  whole 
hand,  marked  upon  the  ulnar  side  (or  it  is  better  to  say 
without  the  excessive  swelling  of  the  thenar  area  which 
characterizes  infection  of  that  space),  aid  us  in  making 

Fig.  73 


Photograph   showing   the  ballooning   of   the   thenar  space  when  filled  with 
pus.    Note  that  the  concavity  of  the  palm  still  remains. 

the  difTerential  diagnosis.  The  obliteration  of  the  con- 
cavity of  the  palm  and  the  presence  of  a  slight  bulging 
is  almost  pathognomonic,  since  while  edema  may  pro- 
duce an  obliteration  of  the  concavity,  I  have  never 
seen  it  produce  a  bulging  or  convexity — a  condition 
which  I  have  seen  in  all  large  abscesses  of  the  middle 
palmar  space.  Attention  is  drawn  to  the  relative 
swelling  of  the  thenar  and  palmar  areas,  since  in  palmar 
infections  the  swelling  of  the  two  might  be  almost  the 
same,  owing  to  the  rigidity  of  the  palmar  fascia  over 
the  one  and  its  absence  over  the  other,  the  swelling 


218     SYMPTOMS,  SIGNS,  DIAGNOSIS  OF  TENOSYNOI'ITIS 

of  the  thenar  space  beini;  due  to  assoeiated  edema. 
On  the  contrary,  however,  infection  ot  the  thenar  area 
is  characterized  by  a  much  greater  sweUing  in  the  thenar 
than  the  more  resistant  pahnar  tissue;  and,  moreover, 
the  swelHng  of  the  thenar  region  is  greater  than  that 
due  to  the  collateral  edema  of  mid-palmar  infection 

(Fig.  73)- 

The  position  of  the  fingers  does  not  aid  much,  al- 
though we  expect  the  middle,  ring,  and  little  fingers  to 
be  held  in  their  characteristic  positions  more  markedly 
than  the  index  when  the  middle  palmar  space  is  in- 
volved, while  the  converse  is  true  in  thenar  space 
involvement.  The  slight  rigidity  of  the  thumb,  in 
contradistinction  to  its  involvement  in  thenar  infection, 
also  aids  one  in  making  the  differential  diagnosis  be- 
tween the  two  spaces.  It  is  well  to  remember  that  the 
fingers  can  be  moved  from  their  position  with  much  less 
pain  than  is  elicited  when  the  fingers  are  involved  in  a 
tenosynovitis. 

The  great  difhculty  in  making  the  diagnosis,  however, 
is  not  in  those  cases  in  which  the  question  is  only 
which  space  is  involved;  it  is  when  we  ask  ourselves. 
Are  they  both  involved?  or  when  we  wish  to  know 
whether  a  mid-palmar  space  infection  has  spread  over 
into  the  thenar  space,  or  vice  versa.  Fortunately, 
however,  the  thenar  space  infection  does  have,  to  a 
certain  extent,  that  induration  which  has  been  spoken 
of  as  being  absent  in  infections  under  the  palmar 
fascia,  and  this  aids  us,  slightly  at  least,  to  differentiate 
between  collateral  edema  and  pus  in  this  space.  More- 
over, the  history  helps  us  some.  Given  a  primary 
palmar  space  infection  for  several  days,  we  note  a 
rapid  increase  of  the  size  of  the  thenar  area;  the  edema 
upon  the  dorsum,  which  has  not  been  so  great  as  that 
upon  the  ulnar  side  of  the  hand,  becomes  greater;  the 
palmar   surface    swelling   becomes   very   marked,    the 


Tin:  M/nniJ.  r //ai  ir    /\i>  r///:\./k  si'ic/.s      _'l'.i 

li>siics  (il  llic  llicii.ir  .irc;i  ^(•ciiiiiiL:  '•'  l».ill<>')ii  diil,  .1-- 
il  were,  iVoiii  llic  ;i(l(lii(  lioii  crcax'  (»l  lln'  iliiiiiili;  llif 
lluiiiil)  mclacarpal  i^  i)iislic(l  a\\a\  as  lai"  as  possil^lc 
Iroin  tlu'  hand,  and  llu-  flexion  of  tlic  distal  i)halanx 
beconic's  more  niarkc-d.  althoui^li  lackin.u,  the  rii;idit>' 
of  synovial  infection  of  the  llexoi'  lon.^us  pollieis.  In 
such  a  case  we  now  fear  an  extension  into  that  si)ace. 
The  extension  of  an  infection  Ironi  the  llienar  to 
the  i)almar  space  is  not  so  common,  fortunately,  since 
diatiuosis  is  made  earlier  and  the  i)r()per  treatment 
instituted. 

The  immense  vsize  to  which  these  infected  hands  may 
i2,row  can  hardly  be  believed  unless  they  are  seen.  I 
recall  particularly  a  patient  who  presented  himself 
with  such  a  hand  which  had  been  treated  for  four 
weeks  without  the  surgeon  having  diagnosticated  and 
opened  a  typical  middle  palmar  abscess.  It  is  that  of 
Mr.  S.,  the  photograi)h  of  whose  hands  I  here  present. 
In  the  photograph  the  two  hands  are  upon  the  same 
level,  and  the  size  of  the  infected  hand  is  not  exaggerated 
in  the  picture.  It  could  be  compared  to  nothing  except 
the  appearance  of  a  large  turtle.  The  patient  had  had 
ten  or  fifteen  incisions  upon  the  fingers  and  dorsum 
of  the  hand  when  I  saw  him.  Only  one  incision — that 
of  the  middle  i)almar  space,  was  necessar>-  for  drainage. 
A  cupful  of  pus  was  evacuated,  and  the  patient  ulti- 
mately recovered  complete  function  of  his  hand,  as 
will  be  seen  by  examining  the  photographs.  He  had 
been  adx'ised  by  several  surgeons  to  ha\'e  his  hand 
^imputated.  There  might  be  some  excuse  lor  the 
failure  to  diagnosticate  the  position  of  i)us,  since  the 
long-continued  infection  had  so  ol)tunded  the  nerves 
that  he  complained  of  no  pain  or  tenderness.  This  is 
onh'  one  of  the  several  cases  that  have  been  seen  some 
weeks  after  the  beginning  of  the  infection  in  which  tlie 
diagnosis  as  to  the  position  of  pus  had  not  lieen  nuuK', 


220     SYMPTOMS,  SIGNS,  DI J  GNOSIS  OF  TENOSYNOVITIS 

and  in  consequence  of  the  apparently  desperate  con- 
dition of  the  hand  the  advice  to  amputate  had  been 
given,  and  yet  upon  proper  drainage  the  patient 
secured  serviceable  hands  (see  Case  Report,  Hender- 
son, Case  XVI). 

Fig.  74 


Photograph  of  dorsum  of  infected  hand.     (See  case  report,  Steiner.)     Note 
multiple  ill-advised  incisions  upon  the  dorsum. 

Case  XII. — Geo.  S.,  Streator,  Illinois.  History  in 
Brief. — Four  weeks  ago  patient  cut  his  right  hand  on 
a  piece  of  steel.  He  was  in  the  hospital  four  days,  and 
it  apparently  recovered.  Following  this,  numerous 
small  pockets  of  pus  developed  upon  the  fingers,  which 
were  opened  by  a  surgeon.  The  hand  began  to  swell 
enormously,  and  incisions  were  made  upon  the  dorsum 


Tin:  MIDDLE  P.II.M.IR   .l.\D   TJ/DA.IR  S/'JCES       221 

of  llie  hand  \vith(Hil  cvacuaLing  nuich  pus.    'Flu-  patient 
began  to  suffer  from  systemic  intoxication. 

Kxdinii/dl/oii  01/   hjilnuice. — General  condilion,  tem- 
peraluri',    i()i°;  pulse,   120;  respirations,  26.      Marked 

Fig.  75 


Photograpli  of  palmar  surface  of  the  same  patient.  Note  wound  leading 
along  lumbrical  muscle  through  which  the  middle  palmar  space  was  drained. 
This  was  the  largest  hand  I  have  ever  seen.  The  pictures  show  the  right 
and  left  hands  respectively  of  the  same  patient.  They  are  on  the  same  level 
and  the  same  distance  from  the  camera. 


headache  and  emaciation;  general  evidence  of  systemic 
intoxication.  Locally,  right  hand  swollen  to  two  and 
one-half  times  normal  size.  The  fingers  are  from  one 
to    one    and    one-half    incdies    in    diameter.     The  hand 


222     SYMPTOMS,  SIGNS,  DIAGNOSIS  OF  TENOSYNOFITIS 

is  at  least  three  Inches  thick,  swollen  both  upon  the 
flexor  and  extensor  surfaces.  Forearm  slightly  swollen. 
Numerous  incisions  upon  fingers  and  dorsum,  from 
which  exude  a  moderate  amount  of  pus.  There  is 
little  or  no  tenderness  about  the  hand. 


Fig.  76 


Result  (case  of  Steiner,  Figs.  74  and  75)  six  months  after  treatment.    Note 
perfect  function  of  all  fingers  and  all  joints. 

Upon  the  bulging  of  the  palm  and  the  lack  of  evi- 
dences of  tendon  sheath  involvement,  a  diagnosis  of 
an  abscess  in  the  middle  palmar  space  was  made. 
Incision  along  ring  finger  lumbrical.  A  cupful  of  pus 
was  evacuated. 

After-history. — Following  the  operation  the  tem- 
perature rose  to  103°,  and  fell  the  next  day  to  99.8°. 
It  rose  to  102°  the  second  day,  and  then  fell  to  99.4°, 
from  which  time  it  gradually  reached  normal.  The 
swelling  slowly  subsided  under  hot  baths  and  active 


DORS.IL  .IBSCESSEH  'ISA 

and  ])assi\-('  niovenuMits,  so  lliat  (he  jjalieiit  k-lt  llu- 
li()S|)ital  at  I  he  end  of  fixf  weeks  with  llirec-foiirths 
fiiiution  in  the  hand,  and  at  the  end  nl  lour  months, 
wlu'ii  I  had  an  o|)i)ortunity  to  examine  the  j)atient, 
the  function  was  perferl  in  every  respect,  as  will  he 
seen  b>'  examining  the  photograjihs  (Figs.  74,  75, 
and  76). 

The  Hvpothknar  Space 

ln\()l\-ement  of  the  h\pothenar  space  can  often  he 
l)rognosticated  from  the  site  of  the  primar>-  injur}', 
while  the  relative  lack  of  swelling  in  the  palm  and 
lingers,  with  ahsence  of  involvement  of  the  tendons, 
combined  with  the  ordinary  symptoms  of  abscess,  lead 
us  to  an  easy  diagnosis.  Fortunateh',  the  hypothenar 
area  is  so  separated  from  the  remainder  of  the  hand 
that  it  is  seldom  involved,  secondarily,  to  palmar 
infection. 

Dorsal  Abscesses 

An  infection  locaHzed  under  the  subaponeurotic 
fascia  to  the  exclusion  of  the  subcutaneous  tissue  ma>' 
be  difficult  of  difTerential  diagnosis.  However,  we  are 
aided  materially  if  we  remember  the  character  of  the 
primary  injury,  the  methods  of  extension  to  this  space 
alread\-  mentioned,  and  the  local  evidences  of  infection 
ujion  the  dorsum,  with  the  pitting  edema  of  the  sub- 
cutaneous tissue,  yet  lacking  the  brawny  induration 
and  localized  tenderness  of  a  subcutaneous  abscess. 

Reference  has  been  made  alread>'  to  the  edema  ui)on 
the  dorsum,  due  to  the  fact  that  there  we  find  a  large 
area  of  loose  subcutaneous  tissue  in  which  serum  can 
accumulate,  and  secondh .  to  the  anatomical  distri- 
hution  of  the  superficial  Kniphalics,  which,  as  we 
ha\c  pointed  out,  all  seek  the  shortest  course  h^oni  the 


224     SYMPTOMS,  SIGNS,  DIAGNOSIS  OF  TENOSYNOVITIS 

palmar  surface  to  the  dorsum.  Consequently,  one  often 
finds  much  greater  swelling  upon  the  latter  than  the 
former,  even  though  the  abscess  be  upon  the  palm. 
If,  however,  we  bear  in  mind  the  soft  pitting  of  edema, 
with  its  generalized  moderate  tenderness,  as  opposed 
to  the  induration  with  slight  pitting  and  localized 
tenderness  of  the  abscess  in  this  tissue,  the  diagnosis 
is  easy.  One  should  never  wait  for  fluctuation  to 
make  a  diagnosis  of  abscess  formation;  it  should  be 
made  from  the  induration. 

Forearm  Abscesses 

It  is  well  at  this  time  to  speak  briefly  of  those  cases 
which  extend  into  the  forearm.  We  remember  that 
this  is  much  more  likely  to  occur  in  the  palmar  space 
infections  than  in  the  thenar  infections  (see  experi- 
ments), although  cases  are  reported  in  which  it  has 
extended  from  either  (Chevalet).  Personally  I  have 
not  seen  a  single  case  in  which  an  extension  occurred 
from  an  uncomplicated  middle  palmar  or  thenar  space 
abscess.  It  most  commonly  arises  from  a  radial  or 
ulnar  bursitis.  Here  we  would  note  the  sudden  in- 
crease of  evidences  of  inflammation  in  the  forearm; 
the  temperature  would  rise,  the  tenderness  over  the 
forearm  in  front  grow  greater,  and  the  swelling  become 
more  marked;  but  owing  to  the  fact  that  the  pus  is 
deep  under  the  muscles,  induration  would  be  absent 
until  later,  when  the  whole  area  became  involved,  and 
it  would  tend  to  come  to  the  surface  probably  a  few 
inches  above  the  wrist,  along  the  vessels  (see  Chapters 
X  and  XXVI  for  a  full  discussion  of  this  subject). 

Exception  must  be  made  of  those  cases  already 
noted  where  the  infection  develops  about  the  radial 
and  ulnar  arteries,  probably  of  lymphatic  origin.  Here 
the  abscess  is  not  so  deep,  yet  is  considerably  below 
the  skin  in  the  area  of  those  vessels. 


l)IFIERi:\TI.IL  D/./(;:\OSfS  225 

Ostconiyclilis,  arlliritis,  and  (jUkt  r(jmi)licaLi(Mi.s  and 
scquehe  have  no  j)ccuHar  relation  to  fascial  space 
infection,  and  hence  will  nol  he  considered  in  (he 
symptoms,  diagnosis,  and  treatment.  The\-  will  he 
reser\'ed   for  a   snl)se(inent    chapter. 

Differential  Diagnosis 

One  ma>-  mistake  a  lymphatic  infection  for  a  teno- 
s>novitis.  Here,  however,  the  red  lines  of  lymphatic 
involvement  running  up  the  arm  without  the  localized 
tenderness  over  the  tendon  sheaths,  the  slight  pain 
on  moving  the  fingers,  the  generalized  edema  of  hand 
and  arm  in  contradistinction  to  the  localized  swelling 
found  in  the  early  stage  of  tenosynovitis  aid  us  in  the 
diagnosis.  Again,  we  may  be  in  doubt  as  to  whether 
we  are  dealing  with  a  tenosynovitis  of  the  ulnar  or 
radial  bursa  or  a  rheumatism  of  the  wTist.  I  have  seen 
several  such  cases.  In  one  case  it  was  difficult  to 
determine  whether  the  patient  was  suffering  from  a 
gonorrheal  rheumatism  of  the  proximal  interpha- 
langeal  joint  of  a  finger  or  a  gonorrheal  tenosynovitis 
with  secondary  involvement  of  that  joint.  The  latter 
assumption  was  later  found  to  be  the  condition  present. 
In  those  cases  where  there  is  a  lack  of  traumatic  his- 
tory and  the  apparently  spontaneous  development  of 
an  inflammation,  especially  at  the  wrist,  the  diagnosis 
may  be  most  difficult  in  spite  of  the  ease  with  which  a 
theoretical  differential  diagnosis  is  made.  Here  again, 
however,  the  localized  tenderness  over  the  sheath  and 
pain  on  extension  of  the  finger  are  of  the  greatest 
importance;  moreover,  these  cases  are  always  virulent 
and  extend  rapidly,  so  that  if  it  be  a  tenosynovitis  the 
hand  grows  rapidly  worse.  In  a  rheumatism  there  is 
as  much  pain  on  the  dorsal  as  on  the  volar  surface; 
the  swelling  involves  the  wrist  more  than  the  hand, 
15 


226     SYMPTOMS,  SIGNS,  DIAGNOSIS  OF  TENOSYNOVITIS 

fingers,  or  forearm;  and  other  joints  may  be  involved 
The  presence  of  a  gonorrhea  does  not  aid  us  materially^ 
since  either  condition  may  follow.  Subcutaneous  in- 
fections are  seldom  difficult  to  differentiate.  One  case 
of  gonorrheal  tenosynovitis  of  the  tendon  sheaths  of 
the  dorsum  of  the  wrist  came  under  my  notice  in  which 
the  diagnosis  of  rheumatism  had  been  made.  Here  the 
absence  of  any  tenderness  or  swelling  on  the  flexor  sur- 
face combined  with  swelling  and  tenderness  localized  to 
the  sheaths  confirmed  the  diagnosis. 

Forssell,  in  a  personal  communication,  has  drawn  my 
attention  to  three  cases  which  came  under  his  observa- 
tion in  which  there  was  a  palmar  infection  represented 
by  necrosis  of  a  part  of  the  palmar  fascia.  This  con- 
dition, he  states,  was  extremely  difficult  to  diagnosti- 
cate from  an  ulnar  bursitis.  Personally,  I  have  not 
met  with  such  a  case  and  can  offer  no  suggestion  as 
to  its  pathogenesis. 


( HAPTKR    XV 

THE  TREATMENT  OF  ACUTE  SUPPURATIVE 
TENOSYNOVITIS 

C.ENERAL  CONSIDERATIONS  ANO  REVIEW  OF  THE 
LITERATURE 

Before  discussing  my  own  views  as  to  the  site  and 
course  of  tlie  incisions  for  the  various  fingers  when  the 
diagnosis  of  tenosynovitis  has  been  made,  let  us  study 
the  suggestions  of  those  who  have  previously  made 
contributions  to  this  subject. 

Professor  Bier  (Berlin),  with  his  assistants,  has  been 
an  active  advocate  of  the  production  of  passive  hyper- 
emia in  these  cases  of  infection  of  the  hand.  His 
method  consists  in  applying  a  constrictor  to  the  arm 
so  as  to  produce  a  moderate  passive  hyperemia  with- 
out causing  pain  and  \vithout  restricting  the  arterial 
flow  of  blood.  The  constrictor  should  be  a  broad  band, 
and  to  prevent  pain  should  extend  from  two  to  four 
inches  up  and  down  the  arm.  It  should  be  so  applied 
that  the  full  amount  of  edema  does  not  appear  at 
once,  .but  accumulates  gradually  for  from  three  to  four 
hours.  The  constrictor  is  left  on  from  sixteen  to 
twenty-four  hours.  After  an  interval  of  from  two  to 
four  hours  it  is  reapplied.  Small  incisions  arc  made 
into  the  tendon  sheaths  or  other  sites  of  pus. 

KlajDp  has  added  to  this  by  suggesting  the  use  of 
suction  cups,  these  being  applied  so  as  to  product' 
moderate  hyperemia  without  pain.  Cups  from  which 
the  air  can  be  exhausted  are  used  o\er  localized  accumu- 
lations of  pus.      Long  glasses  with  rubbers  at   llu'  end, 


228     TREATMENT  OF  SUPPURATIVE  TENOSYNOVITIS 

which  can  be  apphed  over  the  finger,  as  shown  by  the 
illustrations,  have  also  been  devised. 

In  involvement  of  the  connective-tissue  spaces,  it 
is  my  personal  opinion  that  these  appliances  may  be 
of  slight  value.  In  other  conditions  the  benefit  to  be 
derived,  it  would  seem,  is  so  slight  as  hardly  to  justify 
their  use.  Many  German  surgeons  have  maintained 
that  Bier's  methods  are  of  value  in  tendon-sheath 
infections,  but  personally  I  have  never  been  able 
to  secure  good  results  with  them,  except  possibly  in  a 
few  cases  where  there  has  been  a  sinus,  leading  down 
to  a  tendon  sheath.  The  sinus  seemed  to  close  more 
rapidly  under  the  suction  cup  of  Klapp  than  by 
other  means. 

In  order  to  prevent  rapid  absorption  of  toxins,  it 
is  my  habit  to  leave  on  an  Esmarch  constrictor  for 
from  twelve  to  twenty-four  hours  after  operation, 
except  that  a  constrictor  is  loosened  to  produce  only 
a  slight  hyperemia. 

I  cannot  but  feel  that  while  slight  benefit  may  occur 
in  some  cases,  the  so-called  Bier  treatment  of  infections 
of  the  hand  cannot  be  looked  upon  as  a  marked  aid. 

Excerpts  from  the  Literature 

Klapp  and  other  surgeons  have  discussed  the  Bier 
method  of  treatment  in  these  cases  at  the  German 
Surgical  Congress.^ 

Klapp  has  begun  to  make  free  incisions  in  the  tendon 
sheaths  at  the  lateral  surface  of  the  fingers  and  cut  the 
ulnar  bursa  throughout  its  length  with  the  exception 
of  the  anterior  annular  ligament,  using  alcohol  dress- 
ings, and  active  movements  the  first  day.  His  results 
have  apparently  been  as  satisfactory  as  those  obtained 

^  Berliner  klinische  Wochenschrift,  April  13,  1908,  No.  25. 


EXCERPTS  EROM   THE  LITERylTURE  229 

by  Bier  and  Klaj)])  ])rc'vi()usly  where  they  made  small 
incisions  into  the  tendon  sheaths  and  ai)phed  the  Bier 
constrictor.     By  this  methcxl  lie  had  treated   19  cases. 

1.  Ten  cases  of  pure  tendon-sheath  intcctioii;  9 
healed  with  necrosis. 

2.  Two  cases  of  subcutaneous  abscess  under  the 
tendon  with  necrosis  of  the  skin:  I  healed  and  i 
recovered   completely. 

3.  Six  cases  of  tendon-sheath  infection  comj)licate(l 
with  infected  phalangeal  fractures:  2  of  these  healed, 
and  4  became  necrotic. 

4.  One  case  developed  sepsis  and  died  on  the  twelfth 
day. 

Klapp  therefore  concludes  that  he  has  thus  answered 
the  question  as  to  whether  Bier's  good  results  came 
from  h^'peremia  or  from  the  physiological  treatment. 
He  maintains  that  he  has  proved  that  it  came  from 
the  latter.  He  now  proposes  to  study  whether  good 
opening,  physiological  treatment,  and  Bier's  hyperemia 
will  not  produce  still  better  results. 

Klapp's  paper  was  discussed  by  Joseph,  who  sug- 
gested that  there  are  two  types  of  the  infection  which 
must  be  differentiated — (i)  w'here  it  is  localized  to  the 
sheath,  not  showing  a  tendency  to  spread;  (2)  a  t^-pe 
which  show^s  a  tendency  to  spread  beyond,  due  to 
the  great  virulence  of  the  infection. 

He  maintained  that  we  should  use  care  not  to  go 
beyond  the  zone  of  protection  which  Nature  has  thrown 
out  to  wall  off  the  infection,  whether  it  be  within  the 
sheath  or  without.  In  these  cases  we  should  use  the 
smallest  possible  incisions  and  Bier's  hyperemia. 

Kausch  stated  that  he  had  treated  a  large  number 
of  tendon-sheath  infections  after  Bier's  method,  and 
must  say  he  was  generally  well  satisfied  with  the 
result.  He  has  not  been  so  well  satisfied  with  the  very 
severe  cases.     In  the  beginning  he  used  small  incisions, 


230     TREATMENT  OF  SUPPURATIVE  TENOSYNOVITIS 

then  medium-sized,  and  drained  with  passive  hyper- 
emia, but  in  his  severe  cases  he  has  now  gone  back 
to  large  incisions,  although  not  as  large  as  formerly. 

Karewski  stated  that  he  could  not  attribute  his  bad 
results  to  the  Bier  method,  but  rather  to  the  fact  that 
his  material  was  ambulatory  and  could  not  be  correctly 
handled.  He  had  used  the  older  method  for  twenty- 
five  years.  He  now  makes  a  moderate-sized  incision, 
packs  lightly,  and  keeps  the  arm  at  rest  as  long  as 
there  is  fever.  Of  57  cases,  4  had  to  have  amputation 
of  the  fingers  at  once.  Of  the  53  cases  remaining,  9 
were  treated  by  lateral  incisions.  Of  the  53  cases,  42 
showed  good  results,  that  is,  79.25  per  cent.;  bad 
results,  5  cases,  or  9.5  per  cent.  This  result  is  better 
than  that  given  by  Dr.  Klapp. 

Forssell,  in  his  monograph  previously  referred  to, 
has  collected  the  opinions  of  various  surgeons,  and  I 
shall  quote  and  abstract  extensively  from  him.  He 
gives  the  results  of  his  own  experience  as  follows:^ 

"Even  if  one  makes  smaller  incisions  into  the  sheath, 
at  least  according  to  the  experience  met  with  in  the 
Seraphimer-Lazarett,  one  rarely  succeeds  in  saving  the 
sheath  (Poulsen's  experience  was  the  opposite).  I 
have  often  attempted  to  treat  such  an  infection  with 
incision  at  each  end  of  the  tendon  sheath  and  with 
complete  exposure  of  the  surrounding  folds  of  the 
synovialis  (and  subsequent  washing  of  the  sheath  with 
water,  normal  vsalt  solution,  boracic  acid  solution, 
iodoform-glycerin,  weak  carbolic,  or  sublimate  solu- 
tions), but  only  on  three  occasions  was  this  treatment 
successful. 

"The  treatment  which  in  my  judgment  should  be 
used  in  most  cases  is  a  complete  splitting  of  the  sheath 
from  one  end  to  the  other.     Thus,  one  often  succeeds 

1  Nordisches  Med.  Archiv,  1903,  Abt.  i,  Heft  3.  * 


/■:.\(:/:r/'Ts  irom  iiii.  i.iri-.k  iri  kf.  l';;i 

ill    N,i\  iiiL;    .11     l(';i>l     llic    iiiiicf    Iciidoii     lioiii    coinplclc 
iu'(i"()sis. 

"  I'Or  the  opening  ol  (he  iiliiar  slualli  on  ihc  lorcarm, 
If  loi'  this  Ol'  that  reason  one  pretcrs  to  bci^iii  the  in- 
cision here,  scxcral  starlinii  points  arc  at  his  coniniand. 
If  one  can  determine  the  uhiar  |)ulse.  the  skin  incision 
is  made  one  centimeter  to  the  radial  si(h'  thereot.  and 
after  cnttin.u,  through  the  fascia  meets  the  collected 
muscular  bundle  of  flexors  of  the  fini::ers,  at  whose 
ulnar  and  j^ostcM'ior  circumference  the  sheath  extends 
fai'thest  upward;  \)\  ]:)assive  movement  of  the  ulnar 
fini^c'r  it- is  now  a  simi)le  matter  to  know  the  la\'  ot  the 
land.  If  one  does  not  feci  the  ulnar  i)ulse,  nor  the  os 
pisiforme,  which  lies  close  to  the  ulnar  side  of  the 
ulnar  artery,  nor  the  unciform,  on  whose  radial  boun- 
dary the  incision  must  fall,  one  can  make  the  skin  in- 
cision on  the  border  of  the  middle  and  inner  third  of 
the  wrist-joint  and  then  dissect  layer  for  layer  down  to 
the  tendon  sheath. 

"  If  it  is  a  case  of  inflammation  of  the  ulnar  sheath 
of  the  palm,  and  the  tendon  sheath  of  the  little  finger, 
it  is  often  preferable  to  begin  with  the  fissure  of  the 
latter.  Only  in  exceptional  cases  it  might  be  worth 
while  to  use  a  more  conservative  treatment,  and  that 
especially  in  such  cases  of  fresh  tenovaginitis,  where 
this  is  secondary  after  an  ulnar  bursitis;  in  such  cases 
one  can  occasionally  make  an  attempt  to  conquer  the 
inflammatory  process  by  washing  out  the  tendon 
sheath  through  incisions  made  in  either  end ;  there  is 
little  danger  in  this  method,  and  if  successful,  it  insures 
complete  movability  of  the  little  finger. 

"The  skin  incision  must  then  be  laid  from  the  upper 
end  of  the  opened  little  finger  sheath,  up  toward  the 
hook  of  the  unciform  {i.  e.,  must  follow  the  radial 
boundary  of  the  hypothenar),  and  then  continued  in 
the   length   of   the   forearm   to   a   ]X)int   three   or   four 


232     TREATMENT  OF  SUPPURATIVE  TENOSYNOVITIS 

centimeters  or  more  above  the  wrist.  After  cutting 
through  the  skin  and  the  subcutaneous  fat,  usually 
especially  developed  here,  the  palmar  aponeurosis,  the 
strong  anterior  annular  ligament,  and  the  forearm 
fascia  are  cleft,  the  superficial  vessels  cut  through  and 
ligated  (the  ligatures  being  left  long  because  the  vessels 
usually  draw  back  deep  into  the  tissue  and  with  their 
infected  ligatures  give  rise  to  collections  of  pus  which 
might  easily  be  overlooked),  after  which  the  sheath 
is  opened.  Even  when  the  infection  is  confined  to  the 
tendon  sheath,  the  incision  should  be  continued  in  the 
skin  and  soft  parts  until  it  gives  a  good  opening  into 
the  sheath,  through  which  this  can  be  easily  and  com- 
pletely packed  with  gauze. 

"In  continuing  the  incision,  it  must  not  be  allowed 
to  deviate  too  far  to  the  ulnar  side,  as  the  ulnar  nerve 
and  artery  might  thus  be  injured;  the  cut  can  and 
should  be  so  laid  that  neither  of  them  is  exposed.  The 
anterior  annular  ligament  is  best  cut  some  distance 
from  the  hook  of  the  unciform. 

"  If,  however,  it  is  a  question  of  suppuration  of  the 
radial  bursa,  I  believe  that  a  complete  cutting  of  the 
anterior  wall  of  the  bursa  should  not  be  attempted. 
If  the  incision  is  made  in  the  early  stages  of  the  in- 
fection, one  may  have  the  satisfaction  of  seeing  the 
tendon  of  the  thumb  saved  and  the  infection  restricted ; 
the  tendon  cannot,  however,  be  saved  in  all  these 
cases,  and  sometimes,  moreover,  it  is  rendered  useless 
by  adhesions  to  neighboring  regions.  An  incision  of 
the  whole  length  of  the  sheath  is  to  be  regarded  as 
even  more  than  useless  when  it  is  attempted  in  more 
advanced  cases  where  there  is  no  chance  of  saving  the 
tendon  since  the  suppuration  is  kept  up  by  the  necrotic 
tendon ;  moreover  such  an  operation  lames  an  important 
group  of  muscles  and  so  makes  the  thumb  practically 
useless. 


EXCKRrrs  FROM  ■/■///■:  i.irER.irrkK  2'.\'.\ 

"llou  then  should  one  j)n)ccc(I  in  suppurations  of 
this  Older.-'  I  IjcHcnc  llid'c  art-  three  way-s  at  our 
eoniniand. 

"i.  Incision  in  the  radial  bursa  above  and  below 
the  hganientuni  carjji,  sparini^,  the  nerve  of  the  thenar 
group.  The  first  mention  of  this  method  which  I 
have  found  in  the  Hterature  I  found  in  an  article  by 
Nicaise  {Gazette  ninlirdlc  dr  Pnvis,  1870,  s.  615),  who, 
however,  opens  only  the  tendon  sheath  of  the  thumb 
under  the  carpal  ligament  and  not  the  radial  bursa; 
the  case  ended  in  necrosis  of  the  distal  part  of  the 
tendon.  Surely,  then,  if  a  decided  impnn'ement  has 
not  been  shown  within  the  first  twenty-four  hours, 
one  should  proceed  more  radically,  in  which  case  the 
choice  is  between  the  two  follow^ing  methods. 

"2.  Incision  as  in  i,  and  excision  of  the  long  flexor 
tendon  of  the  thumb.  Through  removal  of  the  tendon, 
which  is  usually  the  principal  reason  for  persistent 
suppuration,  one  also  gains  a  lessened  pressure  in  the 
radial  bursa  and  better  drainage  w^ith  less  danger  of 
a  spreading  of  the  inflammation.  Primary  excision 
of  the  tendon  is  to  be  considered:  (i)  When  the  tendon 
is  already  necrotic,  or  its  continuity  broken,  or  if  it 
is  so  injured  that  its  restitution  seems  hopeless;  (2) 
if  the  synovialis  is  infiltrated  with  pus  and  necrotic; 
(3)  in  case  of  inflammation  of  the  joint  or  fracture 
of  the  thumb,  whereby  the  functions  of  either  the 
interphalangeal  joint  or  of  the  tendon  are  completely 
interrupted;  (4)  in  people  of  age  or  poor  general  con- 
dition. 

"3.  A  more  or  less  complete  cutting  of  the  liga- 
mentum  carpi  beginning  at  the  upper  edge  is  added 
to  the  above-mentioned  incision.  Complete  fissure  of 
the  ligamentum  carpi  can  be  carried  out  without  any 
direct  injur}-  to  the  motor  medianus  branch  to  the 
thenar    muscles;    nevertheless,    this    ner\'e    branch    in 


234     TREATMENT  OF  SUPPURATIJ'E  TENOSYNOVITIS 

case  of  an  infection  of  the  edges  of  the  wonnd  might 
possibly  i)e  exposed   to  the  dangers  of  necrosis." 

I  am  in  receipt  of  a  letter  from  Dr.  Forss'ell,  under 
date  of  September  lo,  1908,  in  which  he  reiterates  his 
belief  in  free  incision.      It  is  abbreviated  as  follows: 

"With  regard  to  your  query,  whether  I  have  modi- 
fied my  opinion  of  the  complete  splitting  of  the  tendon 
sheath  from  the  end  of  the  finger  up  into  the  forearm, 
I  must  answer  that  I  still  adhere  to  it  with  the  excep- 
tion mentioned  on  pages  37  and  63  of  my  paper,  i.  e., 
I  still  make  attempts  sometimes  with  smaller  incisions 
and  irrigations  through  the  tendon  sheaths  of  the  thumb 
and  little  finger  when  a  tendon  sheath  has  there  given 
rise  to  an  infection  of  the  radial  or  ulnar  bursa  and  split 
the  tendon  sheath  of  the  finger  only  when  the  smaller 
incisions  do  not  lead  to  the  desired  results. 

/'Prof.  Bier's  hyperemic  treatment  has  been  used 
by  me  for  a  few  cases  of  infection,  but  without  any 
appreciable  benefit,  this  being  also  my  experience  with 
cases  of  tendon-sheath  infection.  The  material  at  my 
disposal  may,  however,  have  been  too  slight  for  my 
forming  an  opinion  of  my  own  concerning  the  value 
of  the  Bier  method  for  tendon-sheath  infections.  At 
the  surgical  department  of  the  Karolinska  Institute 
(The  Royal  Seraphim  Hospital),  where  I  worked  out 
my  paper,  and  where  the  principles  I  advocated  gained 
general  approbation,  and  caused  a  considerable  im- 
provement in  the  results  obtained,  there  was  later  on 
a  good  deal  of  enthusiasm  felt  for  the  method  invented 
by  Bier;  but  I  was  told  that  some  time  ago  the  method 
was  discontinued,  since  it  had  given  several  very 
unfavorable  running  cases,  and  in  the  main  the  former 
old  method  of  treatment  has  been  taken  up  again. 

"Whatever  method  may  be  used,  I  feel  sure  that 
fatal  cases  will  have  to  be  deplored.  As  the  prophy- 
laxis,  therefore,  is    invariably    of    the    very    greatest 


/■'..xcr.Ri'Ts  ikDM  ■/■///■:  i.iri.R.rn  i<i:  i';;.". 

impoi'l.iiicc,  I  li,i\c  l,ilcl\  (uinc  lo  llic  coiulii.'-ioii  llial 
one  \\a\  (il  lr\in;<  to  picxciit  iiilccl  i()ii>  ol  llic  Iiii.l;ci's 
li'oin  attcukiii;<  llu-  Iriidoii  sheathe  is  \)\  prcx  ioiisK' 
exposing'  llu-  tendon  and  tamponin.u,  il  aronnd,  to  the 
extent  of  a  eonple  of  eenlinieters.  'Idiis  ])roeeedinjL; 
shonid  l)e  of  special  nse  in  necrosis  ot  the  vm]  j)hahuix 
of  the  thnnil)  that  so  often  oeenrs  and  which  i;reatl\' 
endangers  the  ten(h)n  sheath  of  the  thnnih  and  thus 
also  the  bursa  of  the  hand. 

"The  method  has  been  proved  b>'  nie  as  yet  in  but 
one  single  case,  though  with  success.  I  then  proceeded 
as  follows:  Tlie  tendon  sheath  of  tlie  thumb  was  split 
to  the  extent  of  a  couple  of  centimeters,  the  tendon 
was  cut  near  its  attachment  on  the  end  phalanx,  and 
was  fixed  l)y  a  suture  in  the  vicinity  to  its  surroundings, 
a  tampon  being  placed  around.  After  this  the  necrotic 
and  phalanx  with  the  tendon  attachment  was  removed. 

"Seeing  the  interest  you  have  for  the  infections  of 
the  hand  in  general,  I  must  call  your  attention  to  the 
small  contribution  I  have  given  in  pages  32  and  33  of 
my  paper.  So  far  as  I  am  aware,  the  isolated  necrosis 
of  the  fascia  palmaris  has  not  previously  been  men- 
tioned in  literature,  which  is  singular,  since  both  from 
a  diagnostic  and  therapeutic  point  of  view  it  is  of 
great  interest.  I  have  recently  had  a  similar  case 
under  treatment.  An  English  sailor  a  fortnight  i)re- 
vious  to  being  admitted  to  the  hospital  had  punctured 
his  hand  with  a  nail.  Besides  the  mark  of  the  injury, 
there  was  great  soreness  in  the  palm,  accompanied  by 
considerable  swelling  of  both  palm  and  back  of  the 
hand,  with  a  very  observable  crooking  of  the  fingers 
together  with  pain  when  moved,  but  no  tenderness 
when  the  fingers  themselves  were  subjected  to  palpa- 
tion. The  diagnosis  was  made  of  a  probable  abscess 
in  or  around  one  of  the  aforesaid  fascia,  which  was 
found  to  be  necrotic  in   the  great  part  of  its  extent. 


236     TREATMENT  OF  SUPPURATIVE  TENOSYNOVITIS 

this  without  any  appreciable  accumulation  of  pus  in 
the  vicinity.  It  would  be  interesting  to  hear  whether 
you  have  had  any  occasion  of  observing  a  case  of  this 
localizing  of  the  infection." 

W.  Heineke,  in  his  Anatomie  und  Pathologic  der 
Schleimheutel  und  Sehnenscheiden,  Erlangen,  1868,  p. 
79,  speaks  of  the  acute  inflammations  of  the  tendon 
sheaths  of  the  hand: 

"The  only  cure  in  these  malignant  inflammations  is 
to  be  found  in  an  early  and  extensive  incision;  thus,  one 
can  sometimes  prevent  a  necrosis  of  the  tendon,  but 
one  must  not  expect  too  much  in  this  direction.  After 
cutting  several  openings,  one  can,  by  use  of  the  drain, 
help  the  outflow  of  pus  and  the  cleaning  of  the  wound." 

An  article  by  Scheide^  shows  what  a  lack  of  even 
elemental  knowledge  there  has  been  in  the  past  in 
regard  to  the  position  of  the  pus  in  these  cases.  He 
warns  against  hot  cataplasm  treatment  of  these  diseases, 
and  recommends  that  introduced  by  Volkmann,  the 
so-called  vertical  suspension  of  the  arm  together  with 
continuous  ice  applications,  and  even  painting  with 
iodine. 

"  In  very  great  swellings,  and  excessive  overfilling 
of  the  veins,  numerous  stabs  with  a  v<ery  sharp  knife 
often  do  good  service.  When  the  period  of  progressive 
inflammation  has  passed  and  with  it  the  danger  of 
death,  when  the  healing  has  begun,  then  the  question 
will  again  be.  What  operations  are  necessary?  Many 
a  necrotic  phalanx,  many  a  finger  whose  tendon  sheath 
has  become  purulent,  will  have  to  be  removed;  and 
now  another  question  becomes  of  primary  importance, 
the  greatest  possible  functional  activity  of  the  remain- 
ing parts. 


1  Ueber  Hand  und  Fingerverletzungen,  Volkmann's  Sammlung  klinischer 
Vortrage,  1871,  No.  29,  Note  i. 


KXCERI'TS   FROM   Till'.   LIT ER.ITr RE  2.37 

"This  laUcr  is  most  Ircciiiciil  l\  hiudcre-d  through 
the  necessary  fixation  of  I  lie  hand  for  weeks  and 
months,  thus  causing  the  lingers  to  lose  a  great  j)art 
of  their  power  of  motion.  The  well-known  changes  to 
which  joints  are  subject  when  kept  stiff  for  a  long 
while  seem  to  take  ]:)lace  esj)ecially  (juickly  in  these 
small  joints  under  the  infiuence  of  rest  and  the  inliam- 
mation  of  the  surrounding  tissue.  One  distinctly  feels 
then  how  in  bending  pseudoligaments  snap  or  the 
capsule  tears.  With  the  necessary  patience  and  endur- 
ance one  can  master  these  disturbances  without  a 
doubt.  But  a  great  deal  of  trouble  to  the  physician 
and  pain  to  the  patient  would  be  avoided  if  immedi- 
ately after  the  first  period  of  reaction  simple  passive 
exercises  were  given  whenever  the  dressing  was  changed, 
and  so  prevent  any  severe  stiffening  of  the  joint." 

Schtiller^  shows  the  same  lack  of  anatomical  knowl- 
edge. His  remarks  are  typical  in  that  they  show  a 
lack  of  tendency  to  make  an  early  diagnosis.  His 
drainage  under  the  anterior  annular  ligament  should 
also  be  condemned.  The  same  may  be  said  concerning 
the  remarks  of  Tilleaux,  which  follow : 

"  If  after  a  tendonal  panaritium  of  the  thumb  a 
doughy  swelling  along  the  arterioradialis  of  the  fore- 
arm is  noticeable,  pressure  there  and  on  either  side  of 
the  ligamentum  carpi  volare  is  very  painful,  while  the 
fingers  are  crooked,  it  is  advisable  to  make  a  few  in- 
cisions immediately,  if  possible,  along  the  line  of  the 
flexor  longus  pollicis,  into  the  tendon  sheath  as  far  as 
the  muscle,  in  order  to  pre\ent  further  changes, 
especially  the  occurrence  of  joyemia  or  septicemia.  The 
incisions  are  made  to  the  best  advantage  on  the  fore- 
arm  outward    (radially)    from   the  arterioradialis  and 


'  ChirurgisL'h-AiKilomisclK'    Stiulicn    ulicr   die    vSehncnsclicidcn   dcr    Hand, 
Dculsche  mcd.  Wuchcnschrit't,  1^7^. 


23<S     TREATMENT  OF  SUPPURATIVE  TENOSYNOVITIS 

along  it.  In  some  cases  this  is  sufficient,  as  evidently 
the  whole  of  the  great  tendon  sheath  is  not  always 
affected  from  the  very  beginning,  but  only  its  radial 
half.  In  other  cases,  further  incisions  in  the  great 
tendon  sheath,  in  the  ulnar  side,  are  necessary.  Here 
an  incision  is  made  to  the  best  advantage  close  above 
the  anterior  annular  ligament  and  at  that,  not  exactly 
in  the  centre,  but  to  avoid  injuring  the  median,  more 
toward  the  ulnar  side  and  in  the  direction  of  the  long 
axis  of  the  forearm.  That  one  should  put  drains  in 
all  incisions  (best  under  the  ligamentum  carpi  volare), 
wash  out  the  pockets  with  an  antiseptic  fluid,  and  band- 
age the  wound  antiseptically,  I  will  only  mention  in 
passing.  Sometimes  even  these  incisions  are  not  suffi- 
cient; then  one  must  add  similar  ones  in  the  palm  and 
in  the  forearm." 

P.  Tilleaux^  speaks  of  the  so-called  subaponeurotic 
abscess: 

"One  must  hasten  to  make  two  incisions,  one  in  the 
palm  of  the  hand,  the  other  in  the  forearm,  connecting 
them  by  a  drainage  tube  which  passes  behind  the 
anterior  annular  ligament  of  the  wrist." 

Concerning  operation  when  a  diagnosis  of  extension 
into  the  forearm  is  made,  he  continues  as  follows:^ 

"It  is  now  well  to  delay  no  longer  in  opening  the 
focus  extensively  without  waiting  for  the  fluctuation 
to  become  more  superficial.  In  reaching  the  skin  the 
pus  must  invade  the  lower  layers  of  the  forearm  and 
also  the  radiocarpal  articulation. 

"  In  making  this  opening  one  must  cut  through  the 
entire  thickness  of  the  antibrachial  region  and  '  manage' 
the  important  organs  there  enclosed,  especially  the 
median  nerve.  Remember  that  this  nerve  is  placed 
slightly  without  the  axis  of  the  forearm;  consequently 

1  Traite  d'Anatomie  topographique,  18S7,  p.  572. 
"^  Traite  de  Chir.  clinique,  1897,  tome  i,  p.  674. 


/■:\(:j:rpts  lkom  the  liier.itiri:  -!:;'.i 

the  place  to  choose  for  the  openiniL;  of  deep  abscesses 
of  the  wrist-joint  is  located  just  inside  the  median  line. 

"At  this  level  make  an  incision  about  4  to  5  cm. 
lonti,  and  successively,  layer  for  layer,  as  il  tor  a  li;<a- 
ture  of  the  artery,  cut  through  all  the  soft  i)arls  ot  the 
forearm  until  you  reach  the  focus. 

"  If  in  the  hand  there  be  a  focus  comnuniicalini:,  with 
thai  of  the  wrist  below  the  anterior  annular  ]iij.amcnt 
of  the  wrist,  it  would  be  necessary  to  drain  it,  and  it 
might  be  even  necessary  to  make  another  opening." 

Farther  on  (pages  684  and  685)  he  not  only  continues 
to  show  a  lack  of  knowledge  of  the  anatomical  and 
pathological  condition  j^resent,  l)ut  advises  i)r()ce(lures 
which  should  be  condemned. 

"Subaponeurotic  abscess.  The  abscess  must  be 
opened  from  the  palmar  face,  always  remembering  that 
the  superficial  palmar  arch  lies  in  a  transverse  line, 
beginning  at  the  nxjt  of  the  thumb.  One  should,  at 
the  same  time,  open  the  abscess  fnjm  the  dorsal  side 
and  establish  thorough  drainage. 

"  If  necessary-,  pass  another  drain,  joining  the  hand 
and  wrist  through  the  radiocarpal  canal.  Long  car- 
bolic baths  should  be  given." 

Konig^  speaks  for  earh'  and  large  incisions,  strong 
antiseptics  (5  per  cent,  carbolic  acid),  drainage,  suit- 
able position  of  the  hand  and  finger  inside  the  bandage, 
vertical  suspension  of  the  arm.  excision  of  the  arm, 
excision  of  the  necrotic  tendon,  but  onh'  alter  a  true 
loosening  has  taken  place. 

"But  even  when  the  teno\'aginitis  has  persist«.-d  lor 
a  long  time,  il  the  abscesses  ha\'e  tormed  along  the 
lorearm  with  sui)i)uration,  much  nia\'  be  atx'oniplished 
with  antiseptic  treatment.  Here,  too,  il  is  a  (]uestion, 
alter  one  or  two  da>'s  of  suspension,  to  slop  the  swell- 

'  Spe'cialc  Chirurgio,  noI.  iii,  pp.  ^(h;,  370. 


240     TREATMENT  OF  SUPPURATIVE  TENOSYNOVITIS 

ing,  of  extensive  opening  of  the  abscesses  and  drainage, 
to  introduce  a  number  of  small  pieces  of  a  drain  into 
the  abscess  openings.  Then  all  the  abscesses  are  dis- 
infected in  the  manner  described  above  and  an  anti- 
septic bandage  applied  (iodoform).  If  one  succeeds 
in  this  wise  in  mastering  the  progress  of  the  disease, 
then  usually  permanent  irrigation  with  salicylic  acid 
will  work  admirably. 

"Large,  widespread  incisions  are  to  be  recommended 
under  such  circumstances,  and  one  should  not  hesitate 
to  do  as  Helferich  has  already  suggested,  under  special 
conditions  to  cut  through  the  transverse  ligament. 
Helferich  recommended  that  after  so  extensive  an 
incision  the  ligament  and  the  wound  should  soon  be 
closed  with  a  secondary  suture,  if  the  phlegmon  is 
receding." 

The  use  of  strong  antiseptics,  particularly  5  per  cent, 
carbolic  acid,  as  suggested  by  Konig,  has  been  almost 
entirely  abandoned.  It  is  recognized  now  that  these 
antiseptics  certainly  impair  the  physiological  function 
of  the  cells  and  probably  do  as  much  harm  as  good. 

E.  Lexer^  says : 

"Good  results  may  be  obtained  only  by  as  early 
and  as  long  an  incision  as  possible." 

B.  Tillmans^  says: 

"  In  light  cases  one  treats  an  acute  non-suppurative 
carpal  bursitis  by  a  high  vertical  position  on  a  splint, 
and  ice.  If  improvement  does  not  follow,  if  suppura- 
tion threatens,  or  if  it  has  already  started,  one  should 
open  the  synovial  sac  by  extensive  incisions  above  and 
below  the  anterior  annular  ligament,  drain  it  and  apply 
an  aseptic  bandage,  preferably  with  a  higher  vertical 
position  on  the  suspension  splint,  according  to  von 
Volkmann.    Strict  precautions  should  be  taken  against 

1  Speciale  Chirurgie,  1902,  s.  726. 

2  Lehrbuch  der  speciallen  Chirurgie,  190 1. 


EXCERPTS  EROM   THE  I.ITER.ITVRE  'JII 

an  extension  of  the  suppuration,  for  (.-xample,  to  the 
forearm." 

P.  L.  Friedrich'  expresses  himself  as  follows: 

'' U  the  inflammatory  process  finally  extends  iij)- 
ward  under  the  cari)al  ligament  and  in  the  manner 
just  described  reaches  the  subfascial  muscular  inter- 
stices of  the  arm,  the  only  advice  one  can  give  is  to  go 
down  with  knife  and  dressing  forceps  into  each  sus- 
pected focus  of  infection,  with  careful  consideration  of 
the  nerves  and  vessels,  and  to  drain  effectually  with 
a  not  too  thin  drainage  material  which  will  not  be 
peisted  together  by  taut  portions  of  the  tissue.  If  it 
is  not  possible  to  guarantee  the  outflow  of  the  pus  in 
a  short  time  to  such  an  extent  in  the  region  of  the 
transverse  ligament,  consideration  of  the  danger  to 
the  carpal  joints  demands  the  cutting  of  the  transverse 
ligament  (Helferich,  Konig)." 

Friedrich's  article  demonstrates  that  even  at  the 
present  time  there  is  a  tendency  to  blind  dissection 
in  these  cases.  The  same  may  be  said  of  the  articles 
appearing  in  the  later  symptoms  of  surger^^  emanating 
from  American  authors. 

P.  Mauclaire,-  in  a  similar  French  system  of  surgery 
(we  find  a  very  similar  description  by  Lyot),  gives  the 
following  description  of  treatment: 

"As  for  the  subaponeurotic  abscess,  if  it  is  a  question 
of  deep  lymphangitis,  or  of  suppurative  synovitis, 
the  incision  should  be  made  where  there  is  fluctua- 
tion, and  the  region  drained,  it  being  possible  for  the 
same  drain  to  go  from  the  palmar  region  to  the  anti- 
brachial  region.  In  making  this  incision  one  should 
guard  the  bloodvessels,  the  nerves,  and  the  tendons. 
One  often  finds  a  focus  of  suppuration  in  the  forearm, 

'  X'lHi  BcryuKinn,  w  15nin>.  w  Mikulir/.,  Handlnu'li  dor  pniktischon  Cliiriir- 
L;ie,  1901,  vol.  iv,  p.  420. 

-  Dentu  ct  Delberl,  Trailo  dc  Cliiruigic,  lyoi,  loine  .\,  and  lomc  iii,  p.  ^i5u. 
♦     16 


242     TREATMENT  OF  SUPPURATIVE  TENOSYNOVITIS 

in  the  median  line  in  front  of  the  pronator  quadratus, 
or  sometimes  between  this  muscle  and  the  inter- 
osseous membrane. 

"To  open  this  focus,  one  should  make  an  incision 
either  on  the  centre  of  the  anterior  face  of  the  wrist, 
along  the  inner  edge  of  the  palmaris  longus,  or  longi- 
tudinally along  the  internal  border  of  the  wrist;  by 
approximately  following  the  anterior  face  of  the  ulna, 
one  makes  a  path  between  the  deep  flexor  and  the 
pronator  quadratus  (Parona)." 

F.  Lejars^  gives  the  following  advice  for  the  treat- 
ment of  deep  phlegmon  of  the  hand: 

"One  must  open  the  palm,  the  great  palmar  sheath, 
then  above  the  wrist,  incise  the  superior  extension,  the 
antibrachial  cul-de-sac  of  the  abscess;  and  last  from 
one  opening  to  the  other  pass  a  drain.  An  operation, 
indeed,  a  difficult  operation  in  such  a  position,  yet 
an  operation  of  immediate  urgency,  if  one  wants  to 
save  this  hand.  This  done,  place  the  member  in  a  con- 
tinuous bath,  leave  it  for  hours  in  the  liquid,  which 
one  renews  from  time  to  time  to  keep  the  temperature 
the  same.  This  will  be  the  best  after-treatment  of 
the  operation  which  you  have  just  made." 

Le jars'  procedure  is  one  that  can  be  carried  too 
far,  since  the  development  of  granulation  tissue  may 
be  excessive,  and  in  my  opinion  the  treatment  should 
be  abandoned  after  twenty-four  to  forty-eight  hours, 
when  the  process  is  found  to  have  come  to  a  standstill. 
After  that  the  hot  bath  may  be  used  at  the  time  of 
dressing  only. 

In  a  treatise  on  the  treatment  of  serious  phlegmons, 
delivered  in  the  Naturforscherversammlung  in  Halle, ^ 
1 89 1,  Helferich,  of  Griefswald,  explains  his  methods  as 
follows:  As  example,  he  takes  a  phlegmon  of  the  hand 

1  Traite  de  chirurgie  d'urgence,  Paris,   1901. 

2  Berliner  klinischen  Wochenschrift,  1892,  No.  4. 


EXCERPTS  FROM  THE  LITERATURE  243 

and  foiTarm,  resulling  from  a  penetrating  injury  to 
the  little  linger,  and  emphasizes  that  such  a  case,  as 
well  as  a  crushed  fracture,  should  be  opened  as  quickly 
as  possible  to  prevent  the  spreading  and  further 
resorption  of  the  i)oisonous  matter  and  the  inflam- 
matory disturbances  of  tendons  and  connective  tissue. 
"After  the  usual  preparations  for  the  operation 
(bath,  deep  narcosis,  cleaning  of  the  operative  field, 
application  of  Esmarch's  bandage),  he  makes  an  ex- 
tensive incision  at  the  point  of  infection,  that  is,  for 
example,  on  the  little  finger,  which  runs  to  the  side  of 
the  flexor  tendon  longitudinally.  An  assistant  care- 
fully draws  apart  the  edges  of  the  wound,  which  are  at 
first  only  slightl}'  gaping,  with  two  little  hooks.  .If 
the  suppurative  channel  is  opened  either  beside  or 
within  the  tendon  sheath,  the  careful  introduction  of 
a  sound  serves  to  control  the  direction  of  the  knife 
and  scissors.  And  so,  the  preparations  having  been 
made,  one  continues  the  incision  farther  into  the  palm 
of  the  hand,  sparing  only  the  tendons,  nerves,  and 
large  vessels,  through  the  anterior  annular  ligament 
over  the  volar  side  of  the  forearm.  Here,  in  case  of  a 
phlegmon  extending  from  the  little  linger,  one  keeps 
to  the  ulnar  side  of  the  common  flexors,  continuing 
upward,  the  region  having  been  prepared  below.  If 
it  is  a  question  of  a  phlegmon  on  the  thumb  side  of 
the  hand  and  the  radial  side  of  the  forearm,  one  would 
proceed  accordingly-,  but  following  the  same  principles. 
The  object  is  complete  exposure  of  the  suppurative 
foci  and  the  prevention  of  the  infiltration  of  pus  into 
the  intermuscular  layers  of  connective  tissue.  Often 
enough  a  focus  somewhat  encapsulated  by  the  sticking 
together  of  the  edges  is  found  between  the  muscles, 
and  even  under  the  flexor  profundus  digitorum,  so 
that  the  interosseous  membrane  is  widely  laid  open. 
Upward   the  incision   first  comes  to   an  end   when   a 


244     TREATMENT  OF  SUPPURATIVE  TENOSYNOVITIS 

thorough  examination  of  the  tissue  and  the  palpation 
of  the  adjoining  region  leads  one  to  expect  healthy 
conditions. 

"So  far  as  necessary,  other  incisions  are  added  to 
this  large  one,  either  on  the  other  side  of  the  palm  or 
on  the  dorsal  side." 

He  is  decidedly  against  any  other  treatment  of  this 
process,  and  has  never  seen  any  good  results  from  small 
punctures;  small  incisions  and  drainage  cannot  effect 
nearly  as  much.  Disinfection  of  the  wound  is  dispensed 
with,  and  he  confines  himself  to  a  careful  washing  out 
with  a  6  per  cent,  salt  solution,  emphasizing  the  local 
injurious,  irritating  effect  of  antiseptics  and  the  very 
unfavorable  effect  of  the  same  on  the  kidneys. 

In  the  after-treatment  he  emphasizes  passive  move- 
ments, baths,  active  movements  in  water  baths,  mas- 
sage, electricity,  occasional  compression,  and  nightly 
fixation  in  various  positions. 

Helferich  then  recommends  an  apparatus  invented  by 
Dr.  Krukenberg  for  the  development  of  passive  move- 
ments. 

C.  L.  Schleich^  says,  in  speaking  of  the  treatment  of 
phlegmons  of  the  palm  of  the  hand: 

"If  we  cut  through  the  ligament  we  can  prepare  for 
the  most  serious  functional  disturbances;  if,  on  the  other 
hand,  we  do  not  follow  up  the  channel  of  suppuration 
we  leave  a  great  mortal  danger.  To  decide  this  matter 
we  press  firmly  on  the  tendinous  convolutions  above 
the  ligament  of  the  forearm  and  pressing  out  the  con- 
tents toward  the  periphery;  we  will  suppose  that  no 
drop  of  pus  flows  from  the  tendon  pocket  below  the 
ligament.  We  are  then  obliged  to  make  a  counter- 
opening  above  the  ligament,  which  would  have  been 
absolutely  necessary  in  the  presence  of  pus  above  the 

1  Neue  Methoden  der  Wundheilung,  Berlin,  1899. 


/■:.\(:/:r/'ts  from  ■riii-  i.iTER.irrRi-.  245 

same.  I  (k'lK'iul  on  (he  appcaraiKX'  of  this  siipcr- 
HganK'iilary  fle'xor  swcllins^  to  decide  whether,  through 
a  counteR)pening,  I  shall  pass  a  drain  of  gauze  strip 
under  the  ligament,  or  whether  I  shall  cut  through  the 
ligament  to  further  lay  bare  the  avenues  of  infection. 
In  case  of  dry  opacity  and  scarring,  I  usually  let  gauze 
drainage  suffice;  if,  however,  fluid  pus  is  found  between 
the  tendons,  I  stand  for  unconditional  severing  of 
the  ligament  and  further  following  up  the  a\'enues  of 
infection." 

K.  Poulsen  (quoted  from  Forssell)  gives  the  follow- 
ing description  of  the  opening  of  the  ulnar  tendon 
sheaths: 

"  If  the  sheath  is  swollen,  or  the  skin  edematous, 
it  is  not  so  easy  to  see  Avhat  one  is  about  or  to  say 
exactly  what  flexor  tendon  lies  before  him  while  he 
is  making  the  incision;  yet  in  these  cases  it  is  of  no 
great  importance  if  one  should  happen  to  get  in  between 
the  deep  flexor  tendons  of  the  second  and  third  fingers; 
the  sheath  when  it  is  stretched  is  always  opened,  if 
one  only  gets  in  between  the  tendons  of  the  deep 
flexor  muscles.  The  incision  is  then  made  in  the  fol- 
lowing manner:  The  arm  is  rendered  bloodless,  and  then 
one  determines  the  position  of  the  M.  flexor  ulnaris 
with  the  help  of  the  os  pisiforme,  its  point  of  insertion, 
and  of  the  tendon  of  the  M.  flexor  carpi  radialis  by 
drawing  a  line  upward  from  the  second  metacarpal 
joint,  to  whose  base  it  is  attached.  Half-way  between 
these  two  tendons  an  incision  is  made  to  the  liga- 
mentum  carpi  volare  proper;  hooks  are  used  to  widen 
the  wound,  with  the  radial  (side)  one  must  be  very 
careful  on  account  of  the  median  nerve.  Next,  he 
proceeds  into  the  depth  between  the  tendons,  tirst 
the  superficial  ones,  then  the  deep-lying  ones;  when 
the  connective  tissue  which  binds  together  the  deep 
tendons  has  been  passed,  the  sheath  is  opened,  the  pus 
streams  out,   with  a   Lister's  forceps  the  opening  of 


246     TREATMENT  OF  SUPPURATIVE  TENOSYNOVITIS 

the  sac  is  dilated  upward  and  downward;  after  this 
iodoform  gauze  is  laid  in,  the  bandage  removed,  and 
the  bleeding  stopped  by  compression. 

"As  a  bandage  I  usually  use  a  boric  acid  applica- 
tion, which  is  changed  daily  while  the  gauze  remains 
undisturbed  until  it  loosens  of  itself;  as  a  support  for 
the  hand  a  volar  splint  is  used.  Some  prefer  to  make 
an  opening  upon  a  bulb-headed  probe  previously  in- 
troduced in  the  vola  manus  on  the  lower  border  of  the 
ligamentum  carpi  volare  proper,  and  to  draw  a  drain 
in  between  the  two  openings.  Yet  I  must  say  that  I 
have  no  particular  fondness  for  using  drains  in  this 
place,  as  they  easily  compress  the  tendons  in  this  com- 
paratively narrow  canal  and  thereby  give  rise  to 
necrosis.  If  the  incision  has  been  made  above  the 
ligament,  and  along  the  tendon  to  the  little  finger, 
there  will  be  an  upper  and  lower  opening  of  the  bursa, 
which,  without  danger  to  the  tendons,  can  be  held 
open  by  gauze  drainage,  which  offers  sufficient  outlet 
for  the  pus,  at  least  so  long  as  the  pus  confines  itself  to 
the  sheath  alone.  If  the  suppuration  lasts  I  prefer 
to  split  the  ligamentum  carpi  volare  proper  and  lay 
open  the  canals;  it  is  not  rare  to  succeed  in  this  way 
in  rescuing  the  tendons,  which  at  this  point  have  a 
fairly  large  vessel  lying  in  mesotendon." 

K.  Poulsen  has  also  discussed  the  therapeutics  of 
tendovaginitis  of  the  thumb  and  radial  bursa.  He 
opens  the  finger  tendon  sheath  to  the  lower  edge  of 
the  M.  abductor  pollicis  and  the  radial  bursa  above 
the  ligament,  avoids  drainage  tubes,  and  in  their 
place  uses  gauze  drainage. 

''In  cases  of  persistent  suppuration  the  ligament  is 
cut  and  a  peritendinous  phlegmon  is  mastered  by  con- 
tinuing the  incision  on  the  thumb  along  the  lower 
border  of  the  abductor,  and  laying  in  drains  when  it 
is  seen  that  the  tendon  will  be  lost;  the  cutting  through 
of  the  muscular  system  of  the  thenar,  used  by  some, 


i':.\ci':kPTs  from  tiif.  i.rri:i<.iri  re  247 

should  be  rc'soiicd  to  oiiK  in  (i('S])crat('  crises,  Ijccausc 
it  destroys  in  larnt-  iiuasiirc  the  function  of  the  ab- 
ductor." 

It  would  sccni  from  this  that  Poulscn,  at  least  in 
coincident  infections  of  the  tendon  sheath  of  the  thumb 
and  the  radial  bursa,  opens  the  latter  only  above  the 
ligament,  and  to  expose  that  part  of  the  bursa  which 
lies  within  the  thenar,  only  when  the  suppuration  has 
spread  beyond  the  bursa.  In  cases  of  persistent  sup- 
puration the  ligament  is  cut;  but  he  does  not  state 
w^hether,  after  this  tardy  fissure  of  the  ligament,  he 
has  found  the  flexor  tendon  of  the  thumb  and  the 
thenar  nerves  capable  of  carrying  on  their  work  or  not. 

"Why  it  should  ever  be  necessary  to  split  the  thenar 
muscles  after  cleaving  the  ligament  I  cannot  see,  as 
only  a  small  upper  point  covers  the  radial  bursa  below 
the  ligament.  Nor  is  it  clear  why  such  a  fissure  of 
the  muscles  in  question  should  destroy  a  great  part 
of  their  functional  activity;  but  the  incision,  continued 
through  the  ligament  and  all  the  soft  parts,  including 
the  tendon  sheath,  cuts  through  the  nerves,  not  only 
of  the  M.  abductor,  but  also  of  the  M.  opponens  and 
of  the  superficial  part  of  the  M.  flexor  brevis,  and  thus 
causes  a  very  troublesome  crippling  of  the  thumb. 

"Finally,  to  use  this  method  of  operation  in  'des- 
perate' cases  will  not  save  the  tendon  of  the  thumb; 
it  is  undoubtedly  better  to  remove  the  tendon,  which 
in  such  a  case  would  undoubtedly  be  destroyed  or 
rendered  useless  at  this  late  date." 

To  open  the  upper  end  of  the  radial  bursa,  Max 
Schiiller  proceeds  as  follows:  The  incisions  are  best 
made  outu^ard  (toward  the  radial  side)  on  the  forearm, 
beginning  at  the  radial  artery  and  extending  along  it. 

Nicaise,  on  the  other  hand,  places  the  incision 
between  the  arterioradialis  and  the  tendon  of  the 
M.  flexor  carpi  radialis,  and  between  the  latter  and 
the  tendon  of  the  AI.  palmaris  longus. 


CHAPTER  XVI 

TREATMENT  OF  ACUTE  SUPPURATIVE 

TENOSYNOVITIS— DISCUSSION  OF 

TECHNIQUE 

Following  the  anatomical  investigations  detailed 
in  the  previous  chapters  and  a  careful  study  of  all 
clinical  cases  coming  under  observation,  certain  pro- 
cedures were  instituted,  which  in  my  hands  have  given 
most  satisfactory  results.  The  technique  used  by 
myself  in  these  serious  cases  is  herewith  described. 
This  may  be  classified  under  three  heads: 

1.  In  the  early  hours  while  the  diagnosis  may  be 
in  doubt. 

2.  When  the  symptoms  and  signs  of  tenosynovitis 
are  marked. 

3.  After-treatment. 

TREATMENT  WHILE  THE  DIAGNOSIS  MAY  BE  IN  DOUBT 

Very  commonly,  when  a  finger  is  infected,  it  is  some 
days  before  the  tendon  sheath  becomes  involved; 
again,  it  may  be  early,  and  when  it  is  invaded  the 
symptoms  develop  rapidly  because,  as  was  mentioned 
above,  there  is  so  little  resistance  that  the  infection 
spreads  throughout  the  sheath  in  a  short  time.  How- 
ever, during  the  preliminary  stage,  much  may  be  done 
to  prevent  a  spread  into  the  sheath.  The  best  sort 
of  application  is  undoubtedly  some  form  of  moist,  hot 
dressing.  Boric  acid  solution  in  saturated  strength  is 
most  commonly  used,  but  any  of  the  other  solutions 
in  common  use  are  probably  just  as  efficient.    Carbolic 


TEciiMinyi':  of  trfitm/'XT  .irriik  nucsosis    2A\) 

acid  dressing  in  ;m\  form  slioiild  be  avoided  because  of 
the  danger  of  gangrene.  Local  i)ainting  with  ichthyol, 
iodine,  and  such  irritating  solutions  is  absolutely  use- 
less. German  surgeons  speak  highly  of  95  per  cent, 
alcohol  dressings  left  on  twenty-four  hours.  They 
probably  arc  no  more  efficient  than  the  hot  boric 
solution,  and  are  always  a  source  of  some  anxiety, 
owing  to  the  possible  danger  of  their  catching  fire,  as 
I  have  personal  knowledge  of  in  one  case.  Probably 
the  next  most  essential  procedure  is  to  keep  the  part 
at  rest;  this,  of  course,  is  indicated  in  any  infection, 
since  the  muscular  action  tends  to  disseminate  the 
germs,  thus  extending  the  area  to  be  walled  off  by  the 
leukocytes  carried  in  by  the  dilatation  of  the  vessels 
incident  to  the  hot  dressings.  Elevation  of  the  part 
is  recommended  by  many,  but  personally  I  could  never 
see  any  advantage  in  it  except  to  make  the  arm  com- 
fortable, and  it  is  true  the  elevation  of  the  hand  is 
sometimes  necessar}^  for  this.  If  the  infection  is  severe, 
put  the  patient  in  bed.  An  ice  bag  in  the  axilla  may 
help  some.  Keep  the  bowels  open  and  the  kidneys 
active.  Preserve  the  nutrition  of  the  patient.  The 
methods  of  Bier  and  Klapp  are  discussed  above. 

TECHNIQUE  OF  TREATMENT  AFTER  DIAGNOSIS  IS  MADE 

The  diversit}^  of  opinions  as  to  the  proper  methods 
of  treatment  held  by  various  surgeons,  as  noted  above, 
is  sufficient  proof  of  the  severity'  of  this  condition  and 
the  ditficulty  of  its  treatment.  It  emphasizes  the 
frequency  of  bad  functional  results,  and  should  stimu- 
late us  to  most  careful  study  of  our  cases. 

The  diagnostic  acumen  of  the  operator  cannot  but 
be  a  vital  factor  in  the  treatment.  It  is  probable  that 
too  many  will  err  on  the  side  of  conservatism  in  the 
treatment  of  the  first  cases  that  are  met.     It  will  be 


250     TREATMENT  OF  SUPPURATIVE  TENOSYNOVITIS 

reasoned  that  since  •some  damage  already  will  have 
occurred  to  the  tendons,  if  they -are  involved,  a  few 
hours'  delay  will  not  add  seriously  to  the  condition. 
This  possibility  will  be  preferred  to  that  of  opening  and 
infecting  an  uninvolved  sheath.  However,  these  few 
hours  are  of  great  importance  in  the  fulminating  type, 
and  operation  should  be  most  prompt. 

I  do  not  intend  this  as  advocacy  of  operation  regard- 
less of  accurate  diagnosis,  but  as  a  stimulus  to  careful 
study  to  the  end  that  the  surgeon,  being  better  qualified, 
may  neither,  by  ill-advised  conservatism,  delay  neces- 
sary operation,  nor  by  thoughtless  audacious  incisions 
jeopardize  the  usefulness  of  a  healthy  hand. 

My  own  opinions  as  to  the  best  methods  are  based 
upon  my  anatomical  researches  and  upon  observation 
of  the  patients  presenting  themselves  at  the  dispensary 
and  hospital  of  the  Post-Graduate  Medical  School  and 
Hospital,  at  Wesley  Hospital,  and  the  Northwestern 
University  Medical  School.  To  Professors  Besley  and 
Richter,  and  others  of  my  friends  at  these  hospitals 
and  at  the  Cook  County  Hospital,  I  wish  to  acknowl- 
edge my  appreciation  of  the  opportunity  for  the  study 
of  their  cases  in  addition  to  my  own.  Concerning  the 
technique  of  treatment,  I  cannot  help  but  feel  that 
the  future  has  much  in  store  for  us  that  we  cannot 
know  at  the  present  time.  The  subject  is  one  not  only 
of  local  condition,  but  of  the  resistance  of  the  individual 
and  his  reaction  to  various  toxins.  In  other  words, 
the  newer  problems  in  serum  pathology  must  first  be 
worked  out  before  we  can  attain  the  best  results.  I 
cannot  but  feel,  however,  that  even  the  local  conditions 
are  not  so  well  understood  by  the  average  surgeon  as 
is  possible,  and  that  our  bad  results  would  be  reduced 
at  least  by  half  if  more  study  were  given  to  careful 
diagnosis. 

I   have   secured   the   best  results  by   the   following 


TREATMENT  OF  TENOSYNO/fTJS  OF  FISCERH       251 

l)r()ceclurcs.  Operation  should  olways  he  dojie  under 
general  anesthesia  and  in  a  bloodless  field.  Where  the 
process  is  virulent  and  acute,  I  leave  on  the  Esmarch 
bandage  for  twelve  to  eighteen  hours  after  the  opera- 
tion. Care  is  taken,  however,  to  loosen  it  so  as  to 
produce  a  passive  hyperemia.  In  other  words,  a  Bier's 
hyperemia  is  secured  for  this  time.  This  is  done  not  so 
much  for  the  therapeutic  effect  as  to  prevent  the  rapid 
absorption  of  virulent  toxins.  I  hope  in  this  manner 
to  give  the  patient  time  to  react  and  develop  anti- 
toxins to  overcome  the  poison  rather  than  allow  him 
to  be  overwhelmed  by  a  large  amount  of  virulent 
toxin  absorbed  at  one  time. 


Treatment  of  Tenosynovitis  of  the  Index,  Middle,  and 
Ring  Fingers 

The  procedure  will  vary  according  to  the  form  of 
infection  and  the  amount  of  destruction  present.  The 
first  incision  is  made  at  the  site  of  known  infection, 
opening  the  sheath  at  the  side  and  not  in  the  median 
line,  cutting  the  length  of  the  shaft  of  the  proximal  or 
middle  phalanx,  leaving  the  part  over  the  articulation 
uncut,  unless  there  is  doubt  as  to  the  freedom  of 
drainage,  so  that  the  tendon  does  not  prolapse.  I 
wish  to  insist  that  the  first  requisite  is  adequacy  of  the 
opening  for  drainage,  since  a  small  incision  soon  be- 
comes closed  by  prolapsing  tissue.  Make  the  incision 
too  free  rather  than  too  small.  In  those  cases  where 
it  has  seemed  advisable  to  incise  the  length  of  the 
sheath,  and  I  do  this  in  case  of  doubt,  I  have  bound 
the  linger  out  in  an  extended  position  to  prevent  pro- 
lapse of  the  tendons.  After  having  opened  the  sheath 
at  this  one  point,  pressure  upon  its  various  parts  will 
give  one  some  idea  of  the  extent  of  the  invasion.  If 
it  is  complete,  as  is  generally  the  case,  a  similar  incision 


252     TREATMENT  OF  SUPPURATIVE  TENOSYNOVITIS 

is  made  over  the  uncut  proximal  or  middle  phalanx. 
No  incision  is  necessary,  as  a  rule,  over  the  distal 
phalanx,  and  in  making  this  I  feel  that  Klapp  is  in 
error,  if  his  drawing  represents  his  technique  correctly. 
Over  the  proximal  end  of  the  sheath,  at  the  base  of  the 
palm,  the  technique  will  vary  according  to  the  extent 
of  the  invasion.  If  early,  the  incision  is  made  over 
the  middle  of  the  sheath  at  its  end  in  the  palm,  carrying 
it  from  the  flexion  crease  at  the  base  of  the  proximal 
phalanx  for  about  three-fourths  of  an  inch  into  the 

Fig.  T] 


Lines  show  area  of  possible  incisions  for  infections  of  the  various  tendon 
sheaths.     (See  text  for  full  description.) 

palm.  If,  however,  there  is  some  question  whether 
the  lumbrical  spaces  at  the  sides  have  begun  to  become 
involved  {vide  supra),  the  incision  is  made  upon  the 
side  most  affected,  opening  the  space  and  the  tendon 
sheath  at  the  same  time.  If  both  sides  are  involved, 
two  incisions  are  made.  The  finger  is  now  cleansed  and 
examined.  If  the  amount  of  pus  is  great,  a  second  line 
of  incisions  is  made  upon  the  opposite  side  of  the  finger 
over  the  two  proximal  phalanges  by  inserting  the 
knife  blade  through  from  the  incision  already  made 


TREATMKXr  OF  T ESOSY SOriTIS  Or  ILM.KRS       25:} 

on  the  one  side  (Fig.  77).  If  there  is  much  involve- 
ment of  the  synovial  surfaces,  or  if  there  is  much 
edema  of  the  linger,  which  would  tend  U)  close  the 
incisions,  1  connect  the  tw(j  hrst  incisions  made,  thus 
making  one  inc/sio)/  llic  /cui^th  of  the  finger  rather  than 
Diii/tiple  incisions  on  both  sides  of  the  finger. 

1  have  tried  cutting  down  to  the  sac  in  doubtful 
cases,'  then  inserting  an  aspirating  needle  and  attempt- 
ing to  draw  off  some  pus  for  diagnostic  purposes, 
hoping  by  this  procedure  to  avoid  the  possibility  of 
infecting  an  uninvolvcd  sheath  through  opening  it 
with  a  scalpel.  While  theoretically  the  procedure  would 
appear  to  1:)e  advisable,  practically  it  is  of  little  aid. 
The  bulging  of  the  sheath,  proving  the  presence  of 
fluid  under  tension,  is  generally  easily  seen,  while  a 
failure  to  secure  pus  is  not  sufficient  evidence  of  its 
absence. 

When  the  Involvement  of  Adjacent  Areas  has 
Begun. — The  involvement  of  the  articulation  between 
the  middle  and  proximal  phalanges,  which  occurs  in 
late  cases,  will  be  discussed  in  the  chapter  dealing  with 
complications  and  sequelae  (Chapter  XXVIII).  The 
method  of  treatment  will  be  outlined  there.  I  shall 
only  add  to  what  I  have  already  said  that  if  early 
incision  of  the  sheath  is  made  this  involvement  is 
generally  ])revented,  another  reason  for  early  incision. 
As  has  been  i)ointe(l  out,  the  paths  of  extension  in  the 
involvement  of  the  lumbrical  spaces  \'ar\'  in  the  in- 
dividual fingers. 

llie  [jidex  Finger. — When  the  intection  passes  to 
the  lumbrical  si)ace  on  the  outer  side,  it  may  extend 
into  the  thenar  si)ace,  and  the  incision  which  opens  the 
lumbrical  space  can  extend  up  into  the  thenar.  Press- 
ure upon   the  thenar  area  will    lorce  pus  out  along  the 

'  WliiU',  Wliitlow  and  its  Trontmenl,  Brit.  Mod.  Jour.,  February  24,  IQ06. 


254     TREATMENT  OF  SUPPURATIVE  TENOSYNOVITIS 

line  of  incision.  This  is  then  extended  along  the  radial 
side  of  the  metacarpal  bone,  the  incision  lying  dorsal 
to  the  web  which  extends  from  the  thumb  to  the  base 
of  the  index  finger.  The  artery  forceps  is  then  carried 
across  the  palmar  surface  of  metacarpal  bone  and  the 
blades  opened,  thus  draining  the  thenar  space  without 
an  incision  upon  the  palmar  surface  (Figs.  89  and  95). 
Care  should  be  used  not  to  force  the  point  of  the  for- 
ceps beyond  the  middle  metacarpal  bone ;  otherwise  the 
middle  palmar  space  will  be  entered  and  an  extension 
to  this  space  favored. 

When  the  extension  has  entered  the  lumbrical  space 
between  the  index  and  middle  finger,  the  incision  should 
be  made  into  the  sheath  at  its  ulnar  side,  thus  opening 
both  the  sheath  and  the  lumbrical  canal  through  the 
same  skin  incision.  If  the  lumbrical  canal  is  badly 
involved,  the  pus  may  have  extended  distally  into  the 
loose  mesh  of  tissue  at  the  web  or  proximally.  If 
distally,  it  may  be  necessary  to  add  a  second  incision 
upon  the  dorsum  between  the  bases  of  the  index  and 
middle  fingers,  and  procure  through-and-through  drain- 
age of  the  web,  or  at  times  I  have  split  the  web  com- 
pletely and  have  not  as  yet  observed  any  serious 
impairment  of  function  following  (Fig.  95). 

If  the  infection  extends  proximally,  some  care 
should  be  used  in  the  incision,  since  it  may  extend 
either  into  the  thenar  or  middle  palmar  spaces.  After 
the  lumbrical  canal  is  opened,  pressure  over  these 
areas  will  demonstrate  which  is  involved,  since  pus 
will  exude  into  the  incision.  This  is  then  extended 
upon  a  grooved  director  along  the  line  of  invasion,  cut- 
ting about  one-fourth  of  an  inch  proximal  to  the  line 
joining  the  ends  of  the  flexion  creases  at  the  distal 
part  of  the  palm;  an  artery  forceps  is  thrust  under  the 
tendon  into  the  space,  which,  by  separating  the  blades, 
is  effectually  opened.     We  frequently  find  invasion  of 


TExosrxorjTis  of  j-jxcer  and  ulsar  bursa    255 

the  thenar  area  either  directly  from  the  sheath  or 
secondarily  by  way  of  the  lunibrical  canals;  when  this 
occurs  I  supplement  this  palmar  incision  by  one  upon 
the  dorsal  surface  between  the  metacarpal  bones  (A 
the  thumb  and  index  finger,  i.  e.,  drainage  of  the 
thenar  sjDace  as  described  in  Chapter  XVII. 

The  Middle  Finger.— Whun  extension  occurs  into 
the  lumbrical  canal  upon  the  radial  side,  or  the  web  on 
either  side,  the  technique  of  treatment  is  as  has  just 
been  described.  When  the  extension  is  along  the  lum- 
brical canal  between  the  middle  and  ring  fingers 
toward  the  palm,  early  the  pus  may  be  between  the 
palmar  fascia  and  the  tendon  in  the  "loft,"  as  already- 
described,  but  it  very  soon  involves  the  middle  palmar 
space.  Here  the  incision  is  carried  one-quarter  inch 
into  the  palm,  i.  e.,  proximal  to  the  transverse  line 
joining  the  ends  of  the  flexion  creases.  If  pus  is  ex- 
pressed through  this  from  the  palm,  an  artery  forceps 
is  inserted  under  the  tendons  going  to  the  ulnar  side 
and  the  blades  opened.  No  drainage  is  inserted,  al- 
though in  a  few  instances  I  have  placed  in  the  pocket 
small  strips  of  gutta-percha  or  gauze  thoroughly  im- 
pregnated with  vaseline.  Ordinary  gauze  acts  simply 
as  a  plug,  and  I  never  use  it. 

The  Ring  Finger. — Here  the  extension  to  the  web 
or  into  the  palmar  space  from  either  side  is  treated  by 
the  same  technique  as  described  above. 

Treatment  of  Tenosynovitis  of  the  Little  Finger  and 

Ulnar  Bursa 

If  the  finger  alone  is  involved,  the  treatment  is  the 
same  as  that  noted  above  for  the  other  fingers,  except 
that  almost  always  it  will  be  found  advisable  to  make 
a  single  incision  on  the  side  the  length  of  the  two 
proximal  phalanges,  since  we  wish  to  procure  perfect 


256     TREATMENT  OF  SUPPURATIVE  TENOSYNOVITIS 

drainage,  and  thus  avoid  possible  extensions.  We 
remember  that  in  about  half  of  the  cases  there  is  a 
congenital  separation  of  the  proximal  from  the  distal 
portion  at  approximately  the  metacarpophalangeal 
articulation,  and  in  a  certain  proportion  of  these  cases 
in  which  there  is  no  separation  the  opening  is  so  nar- 
rowed that  there  is  a  temporary  dam  produced  by 
serous  adhesions  if  the  inflammation  is  not  too  ful- 
minating in  character,  which  unfortunately  it  generally 
is.  In  the  former  condition  there  is  little  likelihood  of 
a  spread  to  the  ulnar  sheath,  so  that  we  should  be  ex- 
tremely careful  not  to  open  this  sheath  unless  we  are 
certain  that  it  has  become  infected,  since  we  are  ex- 
posing the  patient  to  grave  danger.  On  the  other  hand, 
if  the  occlusion  is  of  temporary  inflammatory  origin, 
we  can  readily  see  how  important  it  is  that  an  early 
diagnosis  of  the  condition  should  be  made  and  proper 
treatment  of  the  distal  portion  instituted  to  prevent  a 
spread  to  the  ulnar  sheath.  As  to  just  what  the  proper 
procedure  should  be  in  case  we  are  fairly  certain  that 
there  is  an  infection  of  the  distal  portion  of  the  sheath 
and  we  are  still  in  doubt  as  to  whether  it  has  extended 
to  the  proximal  or  palmar  portion  or  not,  there  is  room 
for  discussion. 

Forssell  advises  that  we  should  begin  at  the  point 
where  we  are  least  sure  of  infection,  while  Helferich 
suggests  that  we  begin  at  the  point  of  infection  where  we 
are  sure  and  make  our  way  along  with  care.  Naturally, 
we  would  admit  the  former  to  be  the  proper  method 
if  certain  unknown  equations  did  not  enter  into  the 
discussion.  In  the  first  place,  what  proportion  of  aseptic 
ulnar  sheaths  can  be  opened  and  not  infect  the  sheath 
from  the  lymphatics  which  are  constantly  carrying 
germs  from  the  point  of  infection  through  the  subcu- 
taneous tissue  in  which  our  so-called  aseptic  incision 
is  made?    Upon  the  answer  to  this  question  depends  in 


TENOSYAO/JTJS  Of  IJXGER  AND  ULNAR  BURSA     257 

all  probabilit)^  the  proper  solution  of  the  cjuestion,  and 
it  will  take  a  larp^e  number  of  earefuUy  observed  cases 
to  arri\  (•  at  a  decision.  Increasing  experience,  however, 
has  (M)nhrnied  nie  in  the  opinion  that  it  is  wiser  to 
incise  at  a  known  jDoint  of  involvement.  This  jKJcket 
being  opened,  pressure  is  exerted  over  the  sites  of  pre- 
dilection in  continuit)  .  if  they  arc  involved,  pus  will 
be  seen  to  enter  the  previously  opened  site.  A  grooved 
director  is  now  inserted  along  the  canal  and  the  incision 
(M)ntiniicd  or  the  fo(^us  opened  by  the  proper  methods. 

Fig.  78 


Lines  represent  the  various  incisions  made  for  infections  of  the  tendon 
sheaths  and  their  possible  extensions  into  the  forearm.  (See  text  for  com- 
plete description.) 

When  the  continuation  of  this  sheath  in  the  hand  is 
involved,  the  j^almar  portion  is  opened  by  an  incision 
extending  from  the  base  of  the  finger  at  the  distal 
flexion  crease  of  the  palm  and  passing  tow^ard  the  base 
of  the  palm  (Fig.  78).  It  is  my  custom  to  insert  a 
grooved  director  in  the  sheath  at  this  point  and  follow 
along  this,  cutting  the  tissues  between  the  sheath  and 
the  surface,  having  the  thought  in  mind  to  avoid  the 
tendon  and  cut  as  far  to  the  ulnar  side  of  the  sheath  as 
possible,  since  there  will  be  better  drainage,  particu- 
larly at  the  wrist,  if  this  is  done  (Fig.  79).  After  the 
anterior  annular  ligament  is  reached,  pressure  above 
over  the  prolongation  of  the  sheath  in  the  forearm  will 
17 


258     TREATMENT  OF  SUPPURATIVE  TENOSYNOVITIS 

force  pus  downward  into  the  sheath  below  the  Hgament 
if  the  infection  has  extended  here,  as  it  generally  has. 

If  an  involvement  of  the  prolongation  of  the  sheaths 
above  the  annular  ligament  or  a  forearm  involvement 
is  diagnosticated,  I  proceed  as  follows.  At  a  point 
about  one  and  one-half  inches  above  the  tip  of  the  ulna 


Fig.  79 


Cross-section  No.  VIII. — See  Fig.  23  for  common  lettering:  i?F  and  iV, 
radial  vessels  and  nerves;  MN  and  V,  median  nerve  and  vessels;  UV  and 
N,  ulnar  vessels  and  nerves ;  PMPS,  prolongation  middle  palmar  space. 

an  incision  is  made  directly  down  on  this  bone  at  its 
flexor  surface,  an  artery  forceps  is  now  thrust  across 
the  flexor  surface  of  this  bone  and  the  radius  until 
it  impinges  on  the  skin  at  the  radial  side,  where  the 
knife  cuts  down  upon  it.  The  incisions  in  the  skin  are 
now  enlarged  to  the  length  of  an  inch  and  one-half  or 
more  and  the  artery  forceps  opens  the  subtendinous 


rENOSYNOriTIS  OF  FINGER  AM)  ULNAR  BLRS.I     250 

area  to  the  same  extent.  Make  the  incision  too  long 
rather  than  too  short,  since  a  large  incision  with  free 
drainage  will  heal  more  rapidly  than  a  small  incision 
with  adequate  drainage.  Especial  care  should  \)v  used 
here  to  make  the  incision  neither  too  far  upon  the  flexor 
surface  nordorsall^',  since  in  the  first  instance,  esi:)ecially 
upon  the  radial  side,  the  artery  may  be  injured  either 
by  the  primary  incision  or  subsequent  necrosis;  and 
in  the  second  instance,  if  the  incision  is  too  far  dorsal 
it  will   not  drain   easily.      If   the   primary   incision   is 


Cross-section  7  cm.  above  radial  stj-loid.  Arter>^  forceps  inserted  trans- 
versely in  juxtaposition  to  ulna  and  radius  through  the  anterior  interos- 
seous space,  showing  that  incision  can  be  made  here  and  not  injure 
important  vessels  and  nerves.  Notice  tissue  between  radial  artery  and 
the  forceps:  r.  a.,  radial  artery;  m.  a.,  ulnar  artery;  u.  «.,  ulnar  nerve; 
???.  71.,  median  nerve. 

made  low  down  and  on  the  radial  side  the  danger  of 
injuring  the  radial  is  greater.  With  the  proper  pre- 
caution, no  anxiety  need  be  felt  (Fig.  80).  Having 
opened  this  area,  the  finger  is  now  inserted  under  the 
flexor  profundus  tendons,  and  if  there  is  any  infection 
of  the  sheath  it  is  bulging  and  can  be  opened  easily. 
In  case  it  is  not  found  easily,  flexion  and  extension  of 
the  fingers  will  locate  the  tendons  involved  and  the  pal- 
pating finger  can  be  pushed  up  among  them,  or  an  arter\- 
forceps  can  be  pushed  under  the  annular  ligament 
through  the  bursa  which  has  been  o]:)ened  in  the  palm 


260     TREATMENT  OF  SUPPURATIVE  TENOSYNOVITIS 

in  front  (Fig.  8i).  Its  point  is  felt  plainly  by  the  finger 
under  the  tendons,  and  the  opening  dilated  freely.  As 
a  matter  of  fact,  the  infection  will  be  found  to  have 
ruptured  into  this  space  in  practically  every  case, 
except  in  the  very  earliest  stages.  /  wish  to  emphazize 
that  it  is  upon  this  incision  that  I  depend  for  drainage 
of  the  upper  end  of  the  bursa,  since  it  extends  upward 
on  the  tendons  on  their  posterior  surface  (Fig.  8i). 
In  other  words,  this  site  is  used  for  entering  and  drain- 
ing the  sheath  before  rupture,  as  well  as  the  site  of 

Fig.  8i 


Drawing  showing  extension  of  the  ulnar  bursa  underneath  dorsal  surface 
of  the  flexor  tendons,  and  probe  inserted  from  a  palmar  incision,  passing 
under  the  anterior  annular  ligament  with  end  showing  in  the  ulnar  bursa 
above. 


incision  for  draining  the  extension  into  the  forearm. 
At  times  when  the  ulnar  bursa  alone  is  involved  the 
incision  upon  the  ulnar  side  has  been  found  sufficient, 
and  I  shall  be  inclined  to  use  that  alone  in  the  future 
in  the  uncomplicated  cases.  It  will  be  remembered 
that  attention  has  already  been  drawn  to  the  fact  that 
when  extension  takes  place  this  area  between  the  flexor 
profundus  tendons  and  the  interosseous  septum  and 
the  pronator  quadratus  is  always  first  involved.  In 
the  early  stages  of  rupture,  after  having  cut  through 


TENosY  sunns  or  ii\c,i:i<  .i\n  ii.s.ir  hl  rsj    2(;i 

the  skin  and  siilxnitaneoiis  tissue,  the  ope  rator  will  he 
iiu'liiK'd  to  di'sisl,  since  no  exidcnceof  i)uswill  be  foinul. 
It  is  not  until  the  area  under  the  i)rofundus  is  reached 
that  one  finds  the  pus.  Again,  a  second  fallacious 
reason  for  stopping  the  incision  at  this  stage  may  be 
found.  There  may  be  a  subcutaneous  accumulation  of 
pus  on  the  flexor  surface  of  the  wrist,  in  all  probability 
of  lymphatic  origin;  this  having  been  opened,  the 
operator  feels  that  he  has  drained  a  pocket  in  direct 
communication  with  the  tendon  sheath  or  may  fear 
that  his  diagnosis  of  tendon  sheath  infection  has  been 
incorrect. 

Because  of  necrosis  of  tendons  or  superficial  involve- 
ment of  the  tendons  above  the  wrist,  it  may  be  deemed 
advisable  to  make  drainage  upon  the  flexor  surface. 
The  anterior  annular  ligament  may  or  may  not  be  cut 
as  is  indicated  in  the  given  case.  If  we  wish  to  open 
the  tendon  sheath  above  the  ligament  without  cutting- 
it,  the  line  of  incision  lies  about  one-half  inch  to  the 
radial  side  of  the  ulnar  artery.  Generally,  however, 
the  swelling  is  such  that  the  pulsation  of  this  vessel 
cannot  be  felt.  It  is  then  necessar^^  to  proceed  by 
choosing  a  point  at  the  junction  of  the  middle  and  ulnar 
thirds  of  the  flexor  surface  and  incising  carefully, 
layer  by  layer,  until  the  group  of  flexor  tendons  is 
reached.  These  can  be  identified  by  moving  the  fingers. 
The  dissection  is  now  carried  down  along  the  ulnar 
border  of  these  tendons  in  juxtaposition  to  them  and 
immediately  above  the  anterior  annular  ligament, 
since  the  sheath  lies  to  the  ulnar  side  and  posterior  to 
the  tendons.  If  infected,  it  should  be  freely  opened, 
since  the  swelling  due  to  edema  and  inflammatory 
infiltration  tends  to  close  a  small  opening.  If  the 
infection  is  now  seen  to  be  at  all  severe,  the  anterior 
annular  ligament  is  split  as  far  to  the  ulnar  side  as 
possible.     The  hook  of  the  unciform  interferes  some- 


262     TREATMENT  OF  SUPPURATIVE  TENOSYNOVITIS 

what  with  the  incision.  If  it  is  determined  at  first 
when  the  palmar  part  is  incised  that  the  anterior 
annular  ligament  shall  be  cut,  one  proceeds  differently. 
The  incision  is  continued  from  below  upward,  carrying 
the  incision  about  an  inch  up  on  the  forearm.  This 
latter  is  made  as  much  to  drain  the  subcutaneous 
area  above  the  wrist,  which  commonly  becomes  in- 
fected, as  to  open  the  sheath.  This  method  of  drainage 
of  the  upper  part  of  the  sheath  and  the  forearm  was 
used  exclusively  in  my  early  cases  before  I  began  to 
use  the  transverse  drainage  under  the  tendons,  and, 
while  fairly  satisfactory,  it  in  no  way  compares  with 
the  transverse  drainage  in  ordinary  cases.  Its  use 
should  be  restricted  to  exceptional  cases. 

Concerning  drainage  in  these  wounds,  it  has  been 
my  experience  that  when  incision  has  been  made  in 
this  manner  no  drainage  material  is  necessary  in  a 
majority  of  cases.  At  times  I  insert  small  strips  of 
gauze  thoroughly  saturated  in  vaseline.  Rubber  tubes 
I  never  use. 

It  seems  especially  unsurgical  to  draw  rubber  tubes 
or  gauze  under  the  anterior  annular  ligament.  The 
drainage  is  not  improved  and  pressure  necrosis  is 
favored.  Moreover,  where  drainage  at  the  wrist  is 
unsatisfactory,  I  have  had  little  cause  to  be  displeased 
with  the  splitting  of  the  anterior  annular  ligament. 
No  case  has  been  seen  in  which  I  felt  that  that  pro- 
cedure per  se  had  resulted  in  loss  of  function,  and  I 
have  frequently  seen  entire  restoration  of  function  after 
it  had  been  cut. 

Treatment  of  Extensions  from  the  Little 
Finger  and  the  Ulnar  Bursa. — The  treatment  of  the 
various  extensions  in  the  finger  proper  is  the  same  as 
that  outlined  while  discussing  the  index  finger.  When 
we  come  to  the  base  we  may  have  extension  either 
into   the  ulnar  bursa,   the  lumbrical  space,   or  both. 


TENOSrAOriTIS  Of  riXC.ER  ,IM)  CLAJR  BURSA     203 

In  the  more  acute  cases  the  fcjinier  alone  is  more  com- 
mon, while  in  the  more  chronic  type  it  is  often  both. 
Here  the  incision  opening  the  tendon  sheath  can  be 
made  to  drain  the  lumbrical  space. 

Extensions  into  the  middle  palmar  space  are  opened 
by  following  along  the  lumbrical  space  as  in  the  other 
fingers,  if  the  ulnar  bursa  is  uninvolved.  If  this  latter 
is  invaded,  the  same  incision  which  opens  the  ulnar 
bursa  may  be  utilized  by  inserting  the  forceps  through 
the  synovial  wall  of  the  bursa  under  the  tendons  into 
this  space.  If  the  pus  has  extended  over  to  the  thenar 
space  it  should-  be  drained  by  making  the  incision  upon 
the  dorsum  between  the  metacarpal  bones  of  the 
thumb  and  index  finger  and  opening  it  by  the  forceps, 
as  was  described  above  when  discussing  the  extensions 
from  the  index  finger. 

The  treatment  of  involvement  of  the  wrist-joint 
will  be  discussed  in  detail  in  Chapters  XXVTI  and 
XXVIII,  dealing  with  chronic  processes  and  compli- 
cations. 

Beginning  invasion  of  the  forearm  has  already  been 
touched  upon.  Those  cases  presenting  marked  in- 
volvement of  the  forearm  are  best  treated  by  incisions 
as  follows  (Figs,  iii  and  114): 

First,  incision  upon  either  side  just  above  the  wrist, 
allowing  drainage  of  the  subtendinous  space  under  the 
profundus  digitorum,  as  described  above.  These  in- 
cisions should  be  increased  to  two  or  three  inches  in 
length  if  the  accumulation  of  pus  is  large.  This  is 
especially  true  of  the  ulnar  side,  where  even  longer 
incisions  can  be  made  with  advantage.  If  the  pus  has 
involved  the  intermuscular  septa  higher  up,  the  incision 
should  be  made  about  half-way  up  the  forearm  upon 
the  ulnar  side,  either  just  above  the  level  of  the  ulnar 
bone  or  about  an  inch  farther  up  on  the  liexor  surface, 
the  desire  being  in  the  first  instance  to  go  between  the 


2G4     TREArMENT  OF  SUPPURATIVE  TENDS YNOFITIS 

flexor  carpi  uliiaris  and  the  ulna.  Here  the  muscle 
must  be  separated  from  the  bone.  In  the  second  in- 
stance we  attempt  to  go  between  the  muscular  body 
of  the  flexor  carpi  ulnaris  and  the  inner  border  of  the 
flexor  sublimis  digitorum.  This  latter  incision  gives 
better  drainage,  but  there  is  some  danger  of  injuring 
the  ulnar  artery  either  primarily  or  secondarily.  The 
incision  between  the  ulna  and  the  flexor  carpi  ulnaris 
is  safer  and  is  sufficiently  satisfactory  to  give  good 
results  in  a  majority  of  cases.  This  one  incision  may 
be  extended  for  three  to  four  inches  and  generally  is 
all  that  is  necessary  in  these  cases.  The  incisions 
through  the  flexor  surface  upon  the  middle  or  radial 
side  should  be  condemned.  Particularly  in  those 
lying  upon  the  middle,  i.  e.,  going  through  the  flexor 
sublimis  digitorum,  the  inflammatory  swelling  of  the 
muscular  mass  acts  as  an  effective  barrier  to  free 
drainage.  I  have  yet  to  see  the  case  in  which  the  ulnar 
incision  supplemented  by  the  incisions  above  the 
wrist,  as  described,  failed  to  give  free  and  satisfactory 
drainage.  (For  a  complete  discussion  of  forearm  involve- 
ment and  treatment  see  Chapters  XXVI  and  XXVII.) 

At  times  it  may  be  necessary  to  make  some  incisions 
through  the  skin  for  the  liberation  of  subcutaneous 
accumulations  of  pus,  probably  lymphatic  in  origin. 
The  most  common  site  for  this  is  immediately  above 
the  wrist  on  the  flexor  surface. 

Secondary  hemorrhage  is  nearly  always  from  the 
ulnar  bursa.  It  will  generally  be  advisable  to  ligate 
this  after  verifying  the  fact  that  it  is  the  vessel  at 
fault,  since  repeated  hemorrhages  are  likely  to  occur  if 
tamponade  is  depended  upon,  and  the  patients  are 
generally  not  in  condition  to  withstand  many  hem- 
orrhages. (For  a  complete  discussion  of  this  subject 
see  Chapters  XXVI  and  XXVII.) 

When  the  radial  bursa  becomes  involved  secondarily 


L\Fi..iMM.iri().\  or  TEXDos  SHE. nil  or  rin  mh    iMi.') 

to  the  ulnar  bursa,  il  should  \)v  healed  as  a  priinai')' 
radial  bursa  infection,  which  we  will  discuss  below. 
Primary  dressing  and  after-treatment  are  discussed  later. 


Treatment  of  Inflammation  of  the  Tendon  Sheath  of  the 
Long  Flexor  of  the  Thumb 

Here  it  is  ni}^  habit  to  dissect  down  to  the  tendon 
upon  the  flexor  surface  of  the  proximal  phalanx;  after 
entering  the  sheath,  the  incision  is  enlarged  along  the 
sac  through  the  thenar  eminence,  separating  the  mus- 
cular mass  (heads  of  the  flexor  brevis  poUicis).  It 
should  be  remembered  that  the  tendon  lies  nearer  the 
palm  than  one  would  be  inclined  to  think,  and  that  the 
mass  of  the  thenar  muscles  lies  to  the  radial  side  of 
the  incision.  This  is  only  carried  up  to  within  a  thumb's 
breadth  of  the  lower  border  of  the  anterior  annular 
ligament.  I  limit  the  incision  at  this  point,  since  with 
the  assistance  of  Prof.  P.  T.  Burns  and  Dr.  A.  T.  Horn, 
at  the  Anatomical  Laboratory  of  the  Northwestern 
University  Aledical  School,  I  made  a  careful  examina- 
tion of  85  cadaver  hands,  with  the  result  that  it  was 
shown  that  the  motor  nerve  to  the  thenar  muscles 
passes  across  the  sheath  between  this  point  and  the 
lower  edge  of  the  anterior  annular  ligament,  and  in 
my  opinion  loss  of  the  flexor  longus  pollicis  tendon  is 
to  be  preferred  to  destroying  this  nerve  and  thus  bring- 
ing about  a  loss  of  the  muscles  which  it  supplies. 
Drainage  of  the  upper  end  of  the  radial  bursa  is  best 
carried  out  by  the  methods  described  above  when 
discussing  drainage  of  the  upper  end  of  the  ulnar 
bursa.  Licisions  are  made  laterally  at  the  flexor  sur- 
face of  the  ulna  and  radius  and  through-and-through 
drainage  secured  under  the  flexor  profundus  tendons. 
At  times  incision  upon  the  radial  side  alone  will  be 
sufficient  if  the  sheath  has  not  already  ruptured.     If 


266     TREATMENT  OF  SUPPURATIVE  TENOSYNOVITIS 

it  has  not  ruptured,  two  fingers  are  thrust  into  the 
radial  incision  under  the  tendons  and  a  grooved  director 
or  forceps  is  pushed  up  from  the  palmar  incision  along 
the  sheath.  The  end  of  the  forceps  is  easily  felt  in  the 
forearm  under  the  tendons.  The  sheath  is  opened  and 
gauze  saturated  with  vaseline  or  gutta-percha  strips 
inserted  into  the  wound  for  drainage.  (For  a  further 
study  of  the  basis  upon  which  this  method  is  advised 
see  Chapters  XXVI  and  XXVII.) 

At  times  an  accumulation  of  pus  will  be  found  on 
the  forearm  subcutaneously  just  above  the  wrist  upon 
the  radial  side.  When  this  is  opened  the  surgeon  may 
be  of  the  opinion  that  the  sheath  has  ruptured  and  is 
thus  draining  anteriorly;  hence,  he  will  desist  from 
drainage  of  the  deeper  tissue.  Such  an  accumulation 
is  of  lymphatic  origin  and  has  no  connection  with  the 
sheath,  so  that  the  lateral  incisions  described  above 
should  always  be  made  in  addition  to  this  skin  incision 
in  front. 

At  times,  owing  to  necrosis  of  tendons  or  extensive 
suppuration  among  them,  it  may  be  advisable  to  drain 
the  sheath  from  the  front,  in  which  case  an  incision 
is  made  going  a  quarter  of  an  inch  to  the  radial  side 
of  the  median  line  of  the  flexor  surface  of  the  forearm. 
The  dissection  is  carried  down  to  the  radial  side  of  the 
flexor  sublimis  tendons,  avoiding  the  median  nerve 
which  lies  in  the  floor  and  to  the  ulnar  side.  The  ten- 
don sheath  has  generally  ruptured  by  this  time,  or  can 
be  identified  by  a  grooved  director  or  fine  probe  passed 
from  the  opened  sheath  below.  It  is  entirely  safe  to 
cut  the  upper  part  of  the  anterior  annular  ligament 
(Fig.  78). 

In  almost  every  case,  however,  I  feel  that  this 
anterior  incision  should  be  limited  to  opening  the 
subcutaneous  accumulation  if  there  be  any,  and  the 
tendon  sheath  should  be  opened  by  the  lateral  incisions 


JNFLJMM.ITJOA  01'  TEA  DON  SHEATH  01  THUMB     l^u 

described  al)ove  for  entering  the  space  between  the 
flexor  profundus  tendons  and  the  pronator  quadratus. 
Good-sized  incisions  should  be  made,  so  that  drainage 
may  be  free. 

In  many  cases  where  the  infection  has  been  severe 
or  the  tendon  impaired  primary  removal  of  the  tendon 
should  be  favored.  This  is  particularly  liable  to  die 
and  remain  for  man}'  weeks,  causing  the  infection  to 
persist  and  jeopardize  other  structures,  so  that  if  the 
tendon  is  at  all  destroyed  or  the  infection  shows  a 
slow  recovery  the  tendon  should  be  removed  at  once. 
I  am  also  especially  inclined  to  do  this  if  the  ulnar 
bursa  has  so  far  escaped  involvement,  since  the  preser- 
vation of  this  is  particularly  to  be  sought. 

The  treatment  of  secondary  involvement  of  the 
thenar  space  and  the  ulnar  bursa  has  already  been 
discussed.  Involvement  of  the  carpal  joints  is  dis- 
cussed in  Chapter  XX I W  In  relation  to  secondary 
ulnar  sheath  infection,  it  may  be  noted  that  there  is 
frequently  doubt  as  to  the  diagnosis  in  these  cases. 
In  such  cases  it  is  advisable  to  dissect  down  carefully 
upon  the  sheath  in  the  lower  third  of  the  palm  just  to 
the  radial  side  of  the  hypothenar  space.  After  the 
palmar  fascia  is  cut  a  pad  of  edematous  fat  will  be 
seen  to  bulge  into  the  wound  as  if  there  were  great 
tension  in  the  subaponeurotic  palmar  space.  This  fat 
having  been  dissected  away,  the  tense  bursa  will  be 
seen  to  bulge  into  the  field.  This  is  opened  and  the 
operation  proceeds  as  described  above  while  discussing 
the  technique  of  treatment  of  the  ulnar  bursa.  There 
is  always  a  grave  decision  to  make  as  to  whether  or 
not  the  sheath  of  the  little  linger  tendon  has  become 
involved,  and  therefore  should  also  be  opened. 

When  the  forearm  becomes  involved,  the  treatment 
is  the  same  as  when  the  involvement  has  originated 


2()S     TREATMENT  OF  SUPPURATIVE  TENOSYNOVITIS 

from  the  ulnar  Ijiirsa,  since  the  foci  of  extension  are 
the  same. 

The  case  of  Mr.  W.  is  reported,  since  it  is  probably 
the  most  virulent  case  of  tenosynovitis  beginning  in 
the  thumb  and  extending  over  by  way  of  the  tendon 
sheath  of  the  flexor  longus  pollicis  to  the  ulnar  bursa 
that  I  have  had  an  opportunity  to  observe.  The 
infection  was  virulent  and  the  toxic  symptoms  so 
severe  as  to  threaten  the  patient's  life.  The  result 
was  very  satisfactory  considering  the  fact  that  the 
case  did  not  come  under  observation  until  after  the 
sheath  had  been  involved  for  at  least  thirty-six  hours. 
In  this  case  there  was  a  complete  restoration  of  func- 
tion of  the  entire  hand  and  fingers,  with  the  possible 
exception  of  slight  loss  of  flexion  of  the  distal  phalanx 
of  the  little  finger.  This  result  is  a  marked  contrast 
to  those  cases  of  similar  nature  which  I  have  seen 
several  days  after  the  sheath  had  become  involved, 
when  such  destruction  of  the  tendons  and  their  cover- 
ings had  taken  place  as  to  preclude  the  possibility  of 
a  favorable  outcome  no  matter  what  the  surgical 
procedure  might  be.  The  history  of  the  case  is  prac- 
tically identical  with  one  seen  two  months  previously, 
which  has  remained  eight  days  without  opening.  The 
general  health  and  resistance  of  the  individuals  were 
much  the  same.  The  outcome  in  the  first  case  which 
had  been  treated  conservatively  was  most  disastrous, 
the  patient  barely  escaping  with  his  life  and  ending 
with  a  functionless  hand.  After  observing  these  two 
cases,  so  close  together  and  with  such  similar  condi- 
tions, I  cannot  but  feel  that  under  these  conditions 
conservatism  is  most  inadvisable,  and  that  the  earliest 
possible  opening  of  the  sheath  is  indicated. 

Case   XIII. — Mr.    W.,    referred   by   Dr.    Colleran, 
Post-Graduate  Hospital,  July,  1908  (Fig.  82). 

Patient  gave  a  history  of  having  run   a  splinter  of 


INFL.lMM.iriOS  or   TKSDON  SHE. ITU  Of   TIUMIi     liC!) 

wood  into  the  distal  phalanx  of  the  thumb  seven 
days  previous  to  coming  to  the  clinic.  This  had  been 
removed  with  a  penknife,  and  later,  at  the  end  oi  five 
days,  another  si)l inter  had  been  removed.  Three  days 
before,  he  began  to  complain  of  pain  over  the  course 
of  the  thumb  and  radial  side  of  the  hand.  The  whole 
hand  now  became  tender  and  swollen. 


Fk;.  S2 


Photograph  showing  the  incision  in  the  case  of  A-Ir.  W.,  spHtting  of  the 
ulnar  bursa  and  radial  bursa  and  incisions  above  the  wrist.  Accompanying 
photographs  show  result  two  and  (ine-half  months  after  treatment.  (Sec 
ease  report,  Case  XIII.) 

On  examination,  temperature  was  101°;  pulse,  90. 
The  whole  hand  was  found  to  be  swollen  on  both  the 
flexor  and  dorsal  surfaces,  as  was  also  the  forearm. 
Concavity  of  the  palm  was  still  present.  Tenderness 
was  most  marked  at  the  wrist-joint  and  slightly  above  on 
both  the  radial  and  ulnar  sides.  There  was  tenderness 
also  along  the  course  of  the  ulnar  l)ursa  in  the  iialin  ot 
the  hand  and  over  the  tendon  sheath  of  the  little  finger. 


270     TREATMENT  OF  SUPPURATIVE  TENOSYNOVITIS 

There  was  only  slight  tenderness  in  the  palm  of  the 
hand.  Tenderness  is  also  found  over  the  course  of  the 
flexor  longus  pollicis.  There  is  no  tenderness  over  the 
index,  middle,  or  ring  fingers  and  none  on  the  dorsum. 
On  extension  of  the  fingers,  extension  of  the  little  finger 
and  thumb  caused  marked  pain,  the  ring  finger  slight 
pain,  and  the  middle  and  index  fingers  very  little  pain. 

Diagnosis  of  tenosynovitis  of  the  flexor  longus  pollicis, 
the  intermediary  sheaths  at  the  wrist,  and  the  ulnar 
bursa  was  made. 

Operation. — General  anesthesia;  Esmarch's  bandage 
applied.  Incision  was  made  through  the  skin  and  sub- 
cutaneous tissue  over  the  ulnar  bursa  in  the  lower 
third  of  the  palm.  After  cutting  through  the  palmar 
fascia  the  fat  bulged  into  the  wound.  This  was  split 
and  the  bulging  sheath  was  seen  beneath.  This  was 
opened  and  pus  found.  The  sheath  was  then  opened 
throughout  its  length  from  the  base  of  the  middle  finger 
up  to  and  through  the  anterior  annular  ligament 
(Fig.  82).  Pus  was  found  throughout.  An  incision 
was  then  made  in  the  forearm  on  either  side  at  the 
level  of  the  flexor  surfaces  of  the  ulna  and  radius,  one 
inch  above  the  anterior  annular  ligament;  an  artery 
forceps  was  passed  underneath  the  tendons  of  the  flexor 
profundus  digitorum.  A  slight  amount  of  pus  was 
found  here.  An  artery  forceps  now  opened  the  sheath 
of  the  ulnar  bursa  at  its  upper  end,  passing  into  the 
space  underneath  the  flexor  tendons,  and  a  finger 
enlarged  the  opening. 

An  incision  was  made  over  the  proximal  end  of  the 
proximal  phalanx  of  the  thumb  into  the  sheath  of 
the  flexor  longus  pollicis.  A  small  amount  of  slightly 
turbid  fluid  was  present  that  was  not  clearly  pus.  The 
opening  was  extended,  however,  to  the  distal  end, 
where  considerable  pus  was  evacuated.  The  incision 
was  then  extended  upward  along  the  sheath  to  within 


INFLAMMATION  OF  TENDON  SUE  AT  II  OF  Till  Mli     L'71 

a  thumb's  breadth  of  the  lower  border  of  the  anteri(jr 
annular  ligament.  Free  pus  was  found  here  also.  An 
artery  forceps  was  then  passed  along  the  sheath  up 
into  the  forearm  underneath  the  flexor  profundus 
tendons,  rommunicating  with  the  ()j)('ning  prcx-iously 
made. 

•  After  washing  the  sheath  out  thoroughly  with  normal 
salt  solution,  strips  of  gauze  saturated  with  vaseline 
were  laid  betw^een  the  cut  edges  of  the  skin  and  also 
drawn  underneath  the  flexor  profundus.  Hot  boric 
dressings  were  applied. 

Subsequent  Course. — Pain  was  immediately  relieved, 
temperature  fell  to  99°,  around  which  it  remained,  at 
no  time  going  higher  than  100°,  and  the  patient  made 
a  gradual  and  satisfactory  recovery.  At  the  end  of 
twenty-four  hours  the  hot  boric  dressings  were  changed 
for  dry  dressings,  the  inner  layer  of  which  was  saturated 
with  vaseline.  The  strips  of  gauze  between  the  edges 
of  the  wound  were  removed,  the  hand  was  dressed  in 
dorsal  extension  on  a  right  angled  dorsal  splint  (Fig.  83). 

Subsequent  Treatment. — Each  day  the  hand  was 
dressed,  each  of  the  articulations  was  moved,  including 
the  finger-joints  and  wrist,  and  the  hand  dressed  in 
dorsal  extension.  On  the  fifteenth  day  it  was  deemed 
advisable  to  open  the  tendon  sheath  of  the  little  finger, 
which  had  not  been  opened  at  the  time  of  operation. 
A  small  amount  of  pus  was  evacuated,  and  I  believe  it 
would  have  been  advisable  to  have  opened  this  sheath 
at  the  time  of  the  primary  operation.  The  incisions 
over  the  flexor  longus  pollicis  were  completely  healed 
at  the  end  of  three  and  one-half  weeks.  Those  above 
the  wrist  closed  at  the  end  of  five  days.  That  over 
the  tendons  of  the  ulnar  bursa  was  completely  closed 
at  the  end  of  four  and  one-half  weeks.  At  that  time 
the  patient  could  move  slighth"  all  the  lingers  ot  the 
hand  and  flex  voluntarily,  with  the  exception  of  the 


272      TREATMENT  OF  SUPPURATIVE  TENOSYNOVITIS 

little  finger,  every  joint,  including  the  wrist.  He  was 
urged  to  use  his  hand  repeatedly  and  to  return  for 
passive  motions.      In  this  respect  he  was  somewhat 


Fig.  83 


Photograph  showing  the  dorsal  right-angled  splint  used  after  splitting  the 
annular  ligament  in  infection  of  the  ulnar  bursa.  In  the  photograph  the  hand 
has  been  loosened  from  the  dressing  so  as  to  show  the  right  angled  splint.     . 


dilatory.  At  the  beginning  of  the  sixth  week  his  hand 
was  treated  daily  in  the  Klapp  apparatus  for  breaking 
up  adhesions,  and  at  the  end  of  the  ninth  week  he 
began  to  work  with  his  hand,  and  at  the  end  of  the 


INIL.IMM.ITIOX  OF  TENDON  SHEATH  OF  TlllMli     2T.\ 

twelfth  week  he  had  practically  complete  function  of 
all  joints  and  fingers,  with  the  exception  of  the  little 
finger,  where  there  was  only  25  per  cent,  of  function. 
This  will  improve,  but  will  never  be  perfect  (Fig.  82). 

The  following  case  of  acute  streptococcic  infection 
of  the  flexor  longus  pollicis  is  reported  in  some  detail, 
since  it  is  one  in  which  the  patient  narrowly  escaped 
with  her  life,  and  shows  the  course  in  these  cases;  and 
because  the  sheath  ruptured  permitting  involvement 
of  the  subprofundus  space  without  involvement  of  the 
ulnar  bursa. 

The  complete  restoration  of  the  tendon  function  in 
this  case  is  most  encouraging.  I  believe  that  with  an 
early  incision,  carefully  followed  by  conservative  treat- 
ment, we  can  hope  for  much  better  results  in  the  future 
than  in  the  past. 

Case  XIV. — Dr.  S.,  seen  in  consultation  with  Dr. 
Besle}',  gave  the  following  history.  This  is  abbreviated 
from  the  history  sheets  of  the  hospital. 

January  23.  Pulse,  100;  temperature,  101.8°;  respira- 
tions, 26.  Hot  dressings  applied  to  right  arm;  under 
nitrous  oxide  anesthesia,  Dr.  M.  L.  Harris  incised  the 
flexor  surface  of  the  thumb.     Condition  good. 

January  24.  Pulse,  80;  temperature,  98.6°;  respira- 
tions, 20.  Sk'i)t  fairl\-  well.  Condition  seems  very  much 
improved. 

January  26.     Leukocytosis,  11,000. 

January  2y.  Pulse,  64;  temperature,  98°;  respirations, 
20.  Entire  thumb  swollen  and  pus  oozes  from  incisions. 
Thumb  again  incised  by  Dr.  Charles  Davison;  drainage 
inserted.  Normeil  salt  enemas  given  every  four  hours; 
hot  boric  acid  solution  to  part;  5  p.m.,  pulse,  80; 
temperature,    101°;    respirations,    20. 

Januar\-  29,  4  A.M.  Pulse,  108;  lenipcralurt'.  102.8°; 
res[)iralions,  26;  8  a.m.,  i)ulse,  80;  temperature,  103.4°; 

IS 


274      TREATMENT  OF  SUPPURATIVE  TENOSYNOVITIS 

respirations,  22;  leukocytosis,  21,000.  Thumb  irri- 
gated with  hot  boric  and  peroxide;  dry  dressings 
appHed;  9  p.m.,  temperature,  102.2°;  palm  of  hand 
greatly  swollen  and  angry  red  extending  into  wrist. 
Vomited  small  amount  of  fluid. 

January  30,  9  A.M.  Temperature,  101.6°;  nauseated 
and  vomited  greenish  fluid ;  face  flushed ;  slept  very 
little. 

January  31,  9  a.m.  Temperature,  101.4°;  pulse,  96; 
respirations,  20.-  Swelling  on  hand  increasing  and  ex- 
tending; under  gas-ether  anesthesia  Dr.  F.  A.  Besley 
made  an  incision  into  the  radial  bursa,  liberating 
yellowish  pus.  Rubber  drain  inserted,  allowing  free 
drainage  between  first  and  second  metacarpals.  Small 
incision  made  above  wrist,  but  no  pus  found  in  arm, 
although  there  was  considerable  redness  and  swelling. 

February  i.  Pulse,  84;  temperature,  102°;  respira- 
tions, 20.  Slept  some  since  10  p.m.  Pain  in  hand.  Hot 
dressings.  Smears  from  pus  show  short  chains  of 
streptococci. 

February  2.  Temperature,  101.6°;  leukocytosis, 
24,000.  Feels  rather  drowsy.  Does  not  have  much 
pain.     Slept  at  intervals. 

February  3.  Pulse,  84;  temperature,  100.2°;  respira- 
tions, 20.  Cultures  on  agar  and  in  bouillon  show  only 
streptococci;  leukocytosis,  32,000.  Under  gas  anes- 
thesia incisions  enlarged  and  opened  wide  by  forceps 
by  Drs.  Besley  and  Kanavel. 

February  4,  i  a.m.  Pulse,  80;  temperature,  102°; 
9  P.M.,  temperature,  101°.     Slept  much  of  forenoon. 

February  5,  10  A.M.  Temperature,  102°.  Hand 
dressed.  Swelling,  hyperemia,  and  tenderness  along 
flexor  surface  of  arm,  radial  side.  Pus  oozes  from 
wounds.  Good  night's  rest;  4  p.m.,  pulse,  112;  tem- 
perature, 103°;  respirations,  24.  Another  incision  made 
in  forearm  by  Dr.  Besley.     The  incision  was  made  on 


INFLAMMATION  OF   T  FN  DON  SIIFATII  OF   TllFMIi     27  r, 

radial  surface  of  arm,  and  liberated  a  large  quantity  of 
yellow  pus.  Gauze  parking  inserted.  Gas  anesthesia. 
7.30  P.M.,  gauze  packing  removed.  Patient  rather 
restless. 

Fel)ruar>-  6.  Pulse,  92;  tenijierat lire,  102°;  resjjira- 
tions,  20. 

February  7.  I'ulse,  90;  temperature,  99.4°;  respira- 
tions, 20.  Patient  very  comfortable.  Small  superficial 
pocket  of  pus  on  anterior  surface  of  wrist  opened  by 
Dr.  Besley. 

February  8.  Pulse,  80 ;  temperature,  98° ;  res{)irations, 
20. 

Fig.  84 


Photograph   showing   the   function   present   in   Case  XI\':    inl\\iion   of   the 
radial  l)ursa,  three  montlis  after  treatment. 

From  this  time  on  the  teniperature  remained'*normal. 
Patient  gradualh'  improved,  and  was  discharged  Febru- 
ary 24.  The  wound  in  the  thenar  si:)ace  closed  about 
two  weeks  later. 

Siihscqitoil  Ilisfory.^  Al  the  end  of  \'\\v  months 
the  case  presents  a  complete  restoration  of  function 
of  the  muscles  of  the  thumb  and  the  tendon  of  the 
flexor  longus  jDollicis,  and  the  tendons  of  the  hand 
upon  flexion  (Fig.  84). 


276     TREATMENT  OF  SUPPURATIVE  TENOSYNOVITIS 

Synovial  Sheaths  on  the  Dorsum 

When  the  synovial  sheaths  upon  the  dorsum  are 
infected,  a  simple  splitting  of  the  sheath  throughout 
its  length  apparently  gives  the  best  results.  I  have  had 
only  four  of  these  cases  due  to  acute  infection,  and  they 
all  recovered  with  good  function  after  a  short  time, 
with  the  exception  of  the  case  in  which  this  involve- 
ment was  associated  with  a  palmar  infection,  in  which 
a  fatal  issue  followed  (Case  XXII). 

AFTER-TREATMENT 

Drainage. — The  use  of  drainage  has  been  discussed 
by  every  surgeon,  and  the  principles  underlying  it  here 
are  the  same  as  elsewhere.  Those  who  after  much 
experience  and  thought  have  decided  upon  its  use  will 
probably  use  it  here.  My  own  results  have  led  me 
to  abandon  it  almost  entirely.  I  never  use  a  rubber 
tube,  owing  to  my  fear  of  pressure  necrosis.  Gauze,  if 
left  in  many  hours,  begins  to  act  as  a  plug.  Unless 
there  is  bleeding,  it  is  not  used.  If,  however,  one  fears 
that  the  skin  will  close  down  at  once  and  prevent  the 
escape  of  pus,  gauze  saturated  with  vaseline  is  inserted. 
I  have  found  this  to  give  good  drainage  and  not  to 
act  so  much  as  a  plug,  yet  giving  tampon  pressure 
in  cases  of  oozing.  Strips  may  be  inserted  from  the 
sides  above  the  wrist  under  the  flexor  profundus,  and 
also  above  into  the  ulnar  incision  on  the  forearm.  I 
have  also  used  gutta-percha  strips  with  satisfaction. 
In  my  earlier  cases  drainage  tubes  were  inserted 
through  from  the  palm  to  the  dorsum,  after  the  older 
methods  of  palmar  drainage,  but  since  introducing 
palmar  drainage  along  the  lumbrical  spaces  this  pro- 
cedure has  been  abandoned  entirely. 

After  the  incisions  are  made  every  part  is  thoroughly 


.-//■  77; A'   TRK.l TMKK T  Til 

washed  out  !)>'  salt  solution  from  an  irrigator  or  pitcher. 
Strong"  antiseptics  are  ne\er  usetl.  In  the  \irulent 
cases,  every  attemj^t  is  made  not  U)  manijjulate  the 
arm  and  hand  an\'  more  tlian  is  necessary,  so  as  to  pro- 
tect the  patient  against  absorption  of  toxins  as  much 
as  possible.  The  application  of  the  Bier  method  of 
constriction  of  the  arm  to  prevent  the  rapid  absorption 
of  bacteria  and  toxins  during  and  immediately  after 
incision  has  already  been  touched  upon.  During  the 
after-treatment  the  same  precautions  are  taken  so  long 
as  the  process  is  acute.  The  area  is  kept  immobilized 
and  slightly  elevated.  This  latter  is  done  to  secure 
comfort  as  much  as  to  aid  in  recovery.  The  von  \"olk- 
mann  treatment,  i.  e.,  vertical  elevation  of  the  hand, 
has  not  seemed  to  me  to  be  of  great  therapeutic  value, 
although  apparently  it  is  a  valuable  procedure  in  that 
it  prevents  excessive  edema  in  the  later  stages. 

For  the  first  few  days  after  incision  it  would  appear 
that  hot,  moist  dressings  are  of  value  to  relieve  the 
pain  and  promote  walling  off  of  the  infection.  After 
this  stage  they  should  be  abandoned  in  favor  of  dry 
dressings,  since  they  seem  to  produce  excessive  granu- 
lation. In  several  cases  I  have  been  able  to  apply  dry 
dressings  at  the  end  of  twent^'-four  hours.  The  hot, 
moist  dressings  are  generally  made  from  a  saturated 
solution  of  boric  acid.  However,  it  is  probable  that 
the  moist  heat  is  the  essential  factor.  Strong  anti- 
septic solutions,  such  as  bichloride  and  carbolic  acid,  are 
never  used.  The  inner  layer  of  the  dr}'  gauze  may  be 
saturated  with  vaseline  to  prevent  it  adhering  to  the 
wound. 

The  hand  is  dressed  from  once  to  twice  daih'.  If 
gauze  has  been  inserted  and  has  adhered  to  the  wound, 
there  is  less  shock  produced  by  anesthetizing  the  patient 
with  a  small  amount  of  nitrous  oxide  than  is  given  by 
the  pain  incident  to  withdrawal  without  such  an  aid. 


278     TREATMENT  OF  SUPPURATIVE  TENOSYNOVITIS 

The  hand  is  dressed  with  the  fingers  in  extension 
upon  a  dorsal  sphnt.  This  is  done  to  prevent  prolapse 
of  the  tendons.  In  the  first  few  dressings  the  hand 
may  be  flexed  and  normal  salt  irrigation  used  to  wash 
out  about  the  tendons.  In  the  fingers  this  procedure 
is  of  special  importance,  not  only  to  avoid  the  pro- 
lapse of  the  tendons,  but  also  to  prevent  all  of  the 
fingers  tending  to  become  flexed  in  one  position. 

The  prolapse  of  the  tendons  at  the  wrist  is  prevented 
by  dressing  the  hand  with  the  wrist  sharply  bent 
backward.  I  ordinarily  mould  a  plaster  of  Paris 
splint  to  fit  the  back  of  the  forearm  up  to  the  wrist; 
here  the  plaster  splint  is  bent  back  at  a  right  angle. 
The  hardened  splint  is  applied  to  the  forearm  and  held 
in  place  by  a  bandage.  A  second  bandage  now  at- 
tempts to  bring  the  hand  back  to  the  horizontal 
prolongation.  At  times  I  have  used  light  elastic 
pressure.  The  tension  and  position  are  varied  from  day 
to  day  after  danger  of  prolapse  has  ended,  so  as  to 
prevent  ankylosis  of  the  tendons  and  joint  in  one 
position.  The  primary  splint  is  applied  immediately 
after  the  operation  (Fig.  83) . 

The  prevention  of  adhesions  in  the  joints,  preserva- 
tion of  the  vitality  of  the  muscles,  and  the  use  of  the 
tendons  is  most  important,  and  at  times  the  results 
are  discouraging.  Unfortunately  the  surgeon  sees  these 
cases  so  often  after  primary  incisions  have  been  made 
and  the  case  treated  for  several  days.  In  those  severe 
fulminating  types  this  has  permitted  such  destruction 
of  the  tendons  and  synovial  coverings  as  to  make  any 
after-treatment  of  little  avail.  It  seems  to  me  advisable 
to  begin  passive  and  active  movements  within  a  few 
days  after  primary  incisions;  in  other  words,  as  soon 
as  the  danger  of  systemic  infection  is  over.  I  do  not 
believe  that  the  local  condition  is  made  materially 
worse,  and  we  do  aid  in  the  prevention  of  firm  adhesions. 


ll'TliR   ■rRI'ITMENT 


270 


1 1  i>  hi'l  Ui'  lo  (l(  I  1 1)  i^  ill  1  I.I  I  lis  ol  \ci\  liol  w  al  cr,  which 
rchi'xcs  ihc  pain  lo  some  cMciil  and  hclp-^  lo  (  Icansc 
the  discharging  wound.  I  he  paliciU's  hand  and  tort-- 
arm  being  immersed  in  hoi  slerilc  walei",  Uu-  surgeon 
with  glove-covered    hands   gently   flexes  and   extends 

Fig.  85 


Sliowing  the  Bier  apparatus  for  proiluction  of  mol)ility  in  stifFcncil 
tendons  and  joints. 


each  finger,  as  well  as  the  hand  at  the  wrist,  se\eral 
times.  Violent  movements  are  not  indulged  in.  The 
bath  is  not  kept  up  any  length  of  time,  since  we 
wish  to  prevent  rather  than  to  favor  the  development 
of    granulation  tissue  at  this   stage.      The  patient  is 


280     TREATMENT  OF  SUPPURATIVE  TENOSYNOVITIS 

encouraged  to  make  active  movements  himself.  If  a 
dry,  hot  chamber  is  at  hand,  this  may  be  used  to  advan- 
tage. I  cannot  emphasize  too  strongly  the  importance 
of  this  early,  gentle,  and  intelligent  manipulation. 
I  do  not  refer  to  massage,  but  to  the  intelligent  use 
of  the  various  joints,  muscles,  and  tendons. 

Bier  (Fig.  85)  and  others  (Fig.  86)  have  used  mechani- 
cal appliances  to  produce  the  same  effect.  The  force 
may  be  exerted  by  exhausting  the  air  in  a  chamber 
in  which  the  hand  has  been  placed,  the  hand  or  the 
individual  fingers  being  applied   to   the  fixed  end,  so 


Showing  the  Klapp  apparatus  for  producing  mobility  in  stiffened  wrist- joint. 

that  when  the  air  is  exhausted  the  joints  are  flexed  or 
extended.  He  attributes  some  of  his  good  results  to 
the  therapeutic  effect  of  exhausting  the  air  and  pro- 
ducing a  hyperemia.  The  apparatus  also  has  the  ad- 
vantage that  the  patient  will  be  more  persistent  and 
regular  in  the  application  of  the  treatment  than  he 
will  be  if  he  depends  on  treatment  by  the  surgeon 
alone.  The  results  of  treatment  may  be  materially 
bettered  by  such  an  apparatus,  as  I  have  had  oppor- 
tunity to  verify  in  my  late  cases.  The  surgeon  must 
not  expect  that  it  will  cure  old  contracted  cases  or 
those  with  great  destruction  of  tissue. 


CHAPTER   XVII 

THE  TREATMENT  OF  FASCIAL  SPACE 
ABSCESSES 

We  shall  here  consider  the  treatment  of  fascial 
space  abscesses  uncomplicated  by  tenosynovitis,  or  in 
case  of  complications  presenting  only  those  of  minor 
importance,  so  that  the  fascial  space  abscess  is  still 
the  predominant  picture. 

The  treatment  naturally  divides  itself  into  prophy- 
lactic and  active.  In  the  first  instance  all  wounds 
should  be  given  aseptic  care,  and  any  localized  infec- 
tion should  be  attended  to,  thorough  drainage  being 
instituted  before  the  infection  has  a  chance  to  spread. 
In  those  cases  in  which  we  are  waiting  to  decide 
whether  or  not  a  localized  abscess  is  present,  immobili- 
zation and  the  local  use  of  the  well-known  hot,  moist 
dressing  is  probably  more  efficient  than  any  other 
application.  The  usual  general  tonic  and  excretory 
procedures  should  be  instituted. 

Should  the  diagnosis  of  a  localized  accumulation  of 
pus  in  any  of  the  various  tissues  be  made,  our  first 
question  is.  What  is  the  best  site  for  incision?  for  we 
need  not  discuss  the  proposition  that  such  a  condition 
as  that  demands  early  and  efficient  drainage.  Should 
the  subcutaneous  tissue  of  the  dorsum  or  the  areas 
under  the  epidermis  or  derma  of  the  palm  be  involved, 
or  minor  infections  of  the  thenar  and  hypothcnar  areas 
be  present,  a  wide  opening  b}'  simple  incision  is  gen- 
erally sufficient.  Should  the  middle  palmar,  thenar, 
lumbrical,  or  subaponeurotic  spaces  be  involved,  how- 
ever, some  special  consideration  is  necessary. 


282        TREATMENT  OF  FASCIAL  SPACE  ABSCESSES 
THE  MIDDLE  PALMAR  SPACE 

Technique  of  Treatment. — The  opening  of  the 
middle  palmar  space  is  a  grave  responsibility;  the 
diagnosis  is  difficult,  and,  on  the  other  hand,  the 
danger  of  delay  is  great.  It  is  probably  better  to  err 
upon  the  side  of  radicalism,  however,  than  conserva- 
tism, owing  to  the  liability  of  complications  in  the 
ulnar  synovial  sheath,  the  bones,  and  the  joints. 

Any  method  of  opening  the  space  exposes  certain 
tissues  to  injury,  and  it  is  a  question  of  choosing  the 
least  dangerous  route.  It  cannot  be  opened  upon  the 
ulnar  side,  owing  to  the  fear  of  infecting  the  ulnar 
bursal  sheath;  a  flap  of  the  palmar  fascia  should  not 
be  dissected  up  from  below,  as  has  been  suggested, 
making  a  sort  of  trap-door,  as  it  were,  since  the  in- 
fection lies  below  the  tendons,  and  to  make  such  an 
opening  and  then  drain  anteriorly  between  the  tendons 
would  result  in  unnecessary  adhesions. 

The  least  injury  and  the  most  efficient  drainage  of 
the  middle  palmar  space  can  be  secured  by  an  incision 
along  one  of  the  three  lumbrical  canals  leading  into 
this  space,  i.  e.,  the  little  finger,  ring  finger,  or  the 
middle  finger  canals  (Fig.  87).  That  canal  will  be 
chosen  which  is  already  markedly  infected,  either  be- 
cause it  has  been  the  atrium  of  the  infection  or  because 
it  has  been  secondarily  involved.  If  the  surgeon  has 
any  choice  in  the  matter,  that  between  the  ring  and 
middle  fingers  gives  the  most  satisfactory  drainage.  An 
incision  is  made  into  the  canal  and  carried  one-half 
inch  above  its  end  up  into  the  palmar  space,  i.  e., 
one-half  inch  proximal  to  a  line  joining  the  proximal 
end  of  the  distal  flexion  crease  with  the  distal  end  of 
the  middle  flexion  crease,  or,  grossly  speaking,  a  thumb's 
breadth  and  a  half  up  into  the  palm.  This  brings  the 
incision   between   the   tendons.     An   artery  forceps  is 


TIIK  MIDDLE  P. II. MIR   SPJCE 


28.3 


thrust  iiiulcr  (In-  i^rniip  ol  paliuai'  Iciu Ions  and  1  he  MaHcs 
()|)('iic(l,  salislacloiA  draiiiai^c  cnsiiini;.  A  small  slrip 
(jf  gutta-i)c'r(ha  or  L^aiizc  saturated  witli  xast-liiu-  will 
keep  the  opening  from  closing  for  a  da>',  after  which 
time  it  will  not  be  needed.     I  think  that  I  am  indebted 


Fi(..  «: 


Showing   incisions  for  opening   Uie  lumbrical  space  and  for  opening  the 
lumbrical  space  in  conjunction  with  the  middle  palmar  space. 

to  Dr.  F.  A.  Bcsley  for  the  suggestion  as  to  this  method 
of  incision.  It  is  remarkable  how  rapidly  cases  will 
recover  under  this  treatment. 

Herewith  is  reported  the  first  case  in  which  I  used 
this  method.  I  have  used  it  man>'  times  since  with 
absolute  satisfaction. 


284  TREATMENT  OF  FASCIAL  SPACE  ABSCESSES 

Case  XV. — Infection  base  of  palm  spreading  along 
lumbrical  canal  into  palm;  incision  along  canal. 
Recovery  with  perfect  function. 

M.  R.,  treated  at  the  Post-Graduate  Hospital,  July, 
1906.  Service  of  Prof.  F.  A.  Besley.  Five  days  before 
entrance  patient  developed  an  infection  from  the  crack 
of  a  callus  at  the  base  of  the  palm  of  the  right  hand 
between  ring  and  little  fingers.  An  abscess  had  formed 
in  the  fascial  space  at  the  base  of  these  fingers  and 
extended  along  the  lumbrical  canal.  Upon  investigation 
it  was  found  to  have  involved  the  middle  palmar  space. 
This  was  diagnosticated  by  the  tenderness  localized 

Fig. 


Photograph  of  incision  in  a  case  of  infection  in  the  middle  palmar  space 
originating  in  web  at  end  of  lumbrical  canal.  Recovery  with  complete  func- 
tion in  ten  days.    Patient — -Relihan.     (See  Case  XV.) 

over  the  lumbrical  canal,  and  the  bulging  of  the  palm 
associated  with  localized  tenderness.  The  incision 
w^as  made  at  the  original  site  of  the  infection,  passing 
from  the  palm  through  the  fascial  tissue  to  the  dorsum 
between  the  proximal  phalanges  of  the  fingers.  A 
grooved  director  was  then  inserted  along  the  lumbrical 
canal,  which  was  opened  throughout  its  extent,  the 
incision  being  carried  up  to  the  middle  flexion  crease 
of  the  palm;  in  other  words,  one-half  inch  above  the 
lumbrical  canal.  Forceps  were  now  inserted  underneath 
the  tendons,  opening  the  palmar  space  widely;  about 
one  ounce  of  pus  escaped,  no  drain  was  inserted,  hot 
boric  dressings  applied. 


TREATMENT  OF  PALMAR  AND  THENAR  SPACES     285 

Course. — At  the  end  of  tt-n  days  all  discharge  of 
pus  had  ceased  and  wound  had  healed.  At  the  end 
of  three  weeks  complete  function  was  present  in  all 
the  ling:crs  and  hand  (Fig.  88). 


The  Treatment  of  Combined  Involvement  of  the  Middle 
Palmar  and  Thenar  Spaces 

The  treatment  here  can  be  best  illustrated  by  quot- 
ing a  typical  case.  Here  the  middle  palmar  and  the 
thenar  spaces  having  been  simultaneously  involved, 
the  forceps  is  passed  from  the  incision  into  the  middle 
palmar  space  under  the  palmar  tendons,  as  already 
described,  and  pushed  through  the  thin  septum  sepa- 
rating the  palmar  and  thenar  spaces  at  the  proximal 
end,  the  point  thus  passing  through  the  thenar  space 
superficial  to  the  adductor  transversus  and  coming  out 
on  the  dorsum  between  the  metacarpal  bones  of  the 
thumb  and  index  finger  (Fig.  89).  A  drainage  strip  is 
then  drawn  through  and  left  eighteen  hours. 

Case  XVI. — Primary  infection,  cracks  from  callus 
on  palm,  extension  into  palm  of  hand,  drainage  of 
middle  palmar  space,  thenar  space,  ulnar  bursa,  and 
forearm.     Recovery  with  perfect  function. 

H.,  Post-Graduate  Hospital.  Two  weeks  before  com- 
ing to  the  hospital  patient  had  developed  an  infection 
in  the  palm  of  the  hand,  evidently  in  the  callus  pro- 
duced by  tongs  handling  ice.  Two  or  three  inadequate 
incisions  had  been  made  when  the  patient  entered  the 
hospital,  with  a  temperature  of  102°  and  an  enormous 
swelling  of  the  entire  hand  and  forearm,  in\olving  the 
palmar  and  dorsal  surfaces.  The  palmar  fascia  bulged 
up  instead  of  presenting  its  normal  concavity,  while  the 
thenar  area  was  ballooned  out  as  if  inflated  to  its 
complete  capacity  .  There  was  redness  and  swelling 
upon  the  flexor  surface  of  the  forearm  i^^•ol^•i^g  par- 


286 


TREATMENT  OF  FASCIAL  SPACE  ABSCESSES 


ticularly  the  lower  third.  The  vSwelhng  upon  the  back 
of  the  hand  was  ascribed  to  edema.  The  fingers  were 
flexed  at  an  angle  of  45  degrees,  while  the  metacarpal 
bone  of  the  thumb  set  back  from  the  hand  and  the 
distal  phalanx  of  the  thumb  was  sharply  flexed.    The 


Fig. 


MPS 
OB 


Drawing  showing  the  drainage  under  tendons. 


diagnosis  of  pus  in  the  middle  palmar  space,  thenar 
space,  the  forearm  under  the  profundus  tendons,  and  the 
probable  involvement  of  the  common  synovial  sheath 
in  the  palm  was  made.  Owing  to  the  inadequate 
incision  already  made  in  the  palm,  this  was  chosen  as 


TREATMENT  OF  PALMAR  AM)  TI/EXAR  S/'ACES     287 


Fic.  'JO 


Photograph  of  llic  liand  of  H.  before  and  after  incision.     Note  I  lie  artery 
forceps  througli  from   the   dorsum   into  the  thenar  space.     In  this  case  the 

anterior  annular  ligament  was  cut.     (,Casc  XVI.) 


288 


TREATMENT  OF  FASCIAL  SPACE  ABSCESSES 


the  proper  site  for  exploration.  The  incision  having 
been  carried  through  the  palmar  fascia,  pus  was  found 
in  the  position  designated  with  the  involvement  of 
the  ulnar  bursa  from  the  base  of  the  little  finger  to 


Fig.  91 


Showing  result  in  the  case  of  H.  three  months  after  treatment.     Note 
perfect  function.     (Case  XVI.) 

the  forearm.  This  was  opened  throughout  its  length, 
cutting  through  the  anterior  annular  ligament.  The 
major  portion  of  the  pus,  however,  la^'  outside  the 
sheath.      An    artery   forceps   was   inserted   under   the 


TREATMENT  OF  l\II.M  IR  SUBAPONEUROTIC  SPACES     289 

Iciidoiis  of  (he  ])alni  Ix-low  ihc  slicalli  and  a  large 
ostium  made.  An  ar(cr\  forcx'ps  was  ihcu  thrust 
tlirougli  tlu'  partition  between  the  thenar  and  middle 
l)ahiiar  spaces  at  the  base  of  the  hand  lying  on  the 
\'olar  side  of  thi'  transversus  pollicis,  coming  out  be- 
tween the  metacarpal  bones  of  the  thumb  and  index 
finger.  A  drainage  strip  was  then  drawn  through  this 
space  of  the  palm  and  left  in  eighteen  hours.  The 
incision,  which  was  carried  through  the  anterior  annular 
ligament  to  the  forearm,  exposed  a  large  abscess  lying 
underneath  the  tendons  of  the  flexor  profundus  digi- 
torum  uix)n  the  pronator  cjuadratus  and  interosseous 
membrane.  The  incision  was  extended  for  three  inches 
up  on  the  forearm  to  open  this  space  completely.  Hot 
boric  dressings  were  applied. 

Course. — Immediate  subsidence  of  temperature  and 
septic  symptoms.  In  ten  days  complete  cessation  of 
discharge,  and  in  two  weeks  all  wounds  were  healed. 
In  three  weeks  the  patient  was  using  his  hand  with 
75  per  cent,  of  function,  and  in  five  weeks  complete 
function  was  present,  as  demonstrated  by  accompany- 
ing photographs  (Figs.  90  and  91). 

This  case  was  one  of  the  worst  that  ever  came  to 
my  notice.  We  were  fortunate,  however,  in  that  no 
necrosis  of  the  tendons  had  taken  place.  The  rapid 
and  complete  recovery  can  be  ascribed  only  to  the 
thorough  opening  of  every  pocket  of  pus  by  incisions 
that  did  not  endanger  previously  uninvolved  areas. 
We  should  also  note  that  the  annular  ligament  was  cut. 

The  Treatment  of  Combined  iNVOLVEifENT  of  the  Middle 
Palmar  and  Subaponeurotic  Spaces 

At  times  we  will  ha\e  crushing  injuries  of  the  hand 
in  which  the  metacarpal  bones  are  fractiu'ed.  Here  the 
subaponeurotic  space  on  the  dorsum  is  involved  in  con- 

19 


290 


TREATMENT  OF  FASCIAL  SPACE  ABSCESSES 


junction  with  the  middle  palmar  space  (Case  VIII).  In 
such  cases  the  through-and-through  drainage  so  much 
in  vogue  among  the  older  surgeons  is  indicated.  Let 
us  study  where  such  drainage  can  be  safely  instituted 
if  it  is  indicated.  Such  a  point  should  be  chosen  as 
would  give  the  most  satisfactory  outlet  to  all  the  diver- 

FiG.  92 


X-ray  plate  made  from  a  hand  in  which  the  middle  palmar  space  was 
injected  with  a  mixture  of  red  lead  and  plaster  of  Paris.  Photograph  repre- 
sents location  of  pus  and  typical  middle  palmar  space  infection. 

ticula,  and  at  the  same  time  injure  the  fewest  structures. 
Here  the  value  of  our  x-ray  plates,  with  the  cross- 
sections  and  injections,  is  invaluable.  We  see  that  the 
mass  always  lies  over  the  interosseous  space  between 
the  ring  and  middle  fingers,  and  that  an  opening  here 
will  drain  all  the  pockets  (Fig.  92).  Our  incision, 
however,   must  lie   proximal   to   the  superficial   trans- 


TREATMENT  OF  P.tLM.IR  SUBAPONEUROTIC  SPACES     291 

verse  ligament  (see  cross-section,  Fi.u.  22;  .v-ra>% 
Fig.  94).  Secondly,  it  must  lir  to  the  radial  side  of 
the  ulnar  bursa  {.v-ra>-  plate,  Fig.  93),  and  must  be  to 
the  ulnar  side  of  the  middle  metarari)al,  or  it  will 
enter  the  thenar  space.  This  again  throws  the  incision 
into  the  metacarpal  space,  between  the  middle  and 
ring  fingers.  Thus  we  see  that  not  only  are  the  few^est 
structures  injured  at  this  site,  l)ut  also  the  most  perfect 
drainage  is  instituted. 

Fig.  93 


A'-ray  plates,  representing  the  location  of  pus  in  the  thenar  space,  with  its 
relation  to  the  ulnar  bursa. 


Now  let  us  consider  where  an  incision  should  lie 
in  this  space.  An  examination  of  the  .r-ray  picture 
(Fig.  94)  shows  the  deep  palmar  arch  running  across 
this  area,  at  the  upper  end;  the  fine  lines  drawn  trans- 
versely represent  the  dense  transverse  ligament  while 
the  cur\ed  lines  represent  the  j-)almar  creases.      It  is  thus 


292 


TREATMENT  OF  FASCIAL  SPACE  ABSCESSES 


seen  that  at  the  point  where  the  middle  palmar  crease 
crosses  the  metacarpal  space  should  be  the  indicated 

Fig.  94 


X-ray  Plate. — Boundaries  of  the  thenar  and  middle  palmar  spaces  marked, 
and  proper  site  for  opening  the  latter  indicated.  Ulnar  bursa  and  blood- 
vessels injected.  Photograph  made  for  me  by  Dr.  Cubbins'  Surgical  X-ray 
Laboratory. 

site  for  drainage.    Making  a  cut  here  through  the  palmar 
aponeurosis,  and  then  forcing  a  pointed  artery  forceps 


TREATMENT  OF  .l/iSCESSES  IN   THE   TIIEX.IR  S/'.ICE     21K{ 

throLiK'i  ^'■>  lli<^'  chji'suni,  l^ciiii;  (aifliil  to  iiipliirc  llic 
dorsal  aponcuro.sis  freely,  we  draw  lliroiiu,!)  a  lar.i;c 
twisted  gutta-percha  slrij).  At  this  site  llicre  is  Httle 
danger  of  a  pressure  necrosis  of  the  uhiar  bursa  or  the 
l)almar  arches. 


TECHNIQUE  OF  TREATMENT  OF  ABSCESSES   IN   THE  THENAR 

SPACE 

Should  the  thenar  area  be  involved,  the  indications 
for  radical  operation  are  absolute,  even  ui)on  less 
evidence  than  in  the  case  of  palmar  infection,  since 
here  the  dangers  of  delay  are  greater,  and  the  conse- 
quences of  opening  the  space,  even  though  uninfected, 
are  not  serious  (see  Case  VI,  in  which  space  was 
opened  when  uninfected,  under  mistaken  diagnosis). 
Here  the  pus  lies  either  anterior  to  the  adductor 
transversus,  or  upon  both  its  dorsal  and  palmar 
surface.  Theoretically,  the  most  available  place  to 
open  would  lie  to  the  radial  side  of  the  index  meta- 
carpal, where  a  free  incision  would  drain  both  in  front 
and  behind  the  adductor.  We  therefore  make  an 
incision  through  the  dorsum,  on  the  radial  side  of  the 
index  metacarpal  and  opposite  its  middle,  and  on  a 
level  with  its  flexor  surface.  An  artery  forceps  is  then 
thrust  into  the  thenar  space  across  the  flexor  surface 
of  the  index  metacarpal.  This  gives  perfect  drainage 
and  leaves  no  scar  upon  the  flexor  surface  of  the  hand. 
Care  should  be  taken  not  to  pass  the  arter\-  forceps 
beyond  the  middle  metacarpal  bone,  for  fear  of  spread- 
ing the  infection  to  the  middle  palmar  space  (Fig.  95). 

Illustrating  these  facts,  the  following  case  may  be 
cited : 

Case  XVII. — K.,  injured  September  3,  1904.  The 
sharp  point  of  a  meat  tongs  ran  into  the  thenar  area 
upon  level  of  the  extended  thumb  about  2  cm.  from  the 


294        TREATMENT  OF  FASCIAL  SPACE  ABSCESSES 

thenar  adductor  crease.  Pain  and  swelling  ensued  the 
following  day.  On  September  5  he  consulted  a  physi- 
cian, who  found  much  redness  and  swelling  upon  the 
dorsal  thenar  area  and  made  an  incision  there,  but 
evidently  failed  to  evacuate  pus.     Hot  dressings  were 

Fig.  95 


Showing  incisions  made  upon  the  dorsum  of  the  hand.  That  upon  the 
thenar  space  is  made  to  drain  the  thenar  space  and  the  palm.  Those  upon 
the  distal  part  are  made  to  drain  extensions  from  the  palmar  space  to  the 
dorsum  and  the  so-called  collar-button  abscesses  when  they  extend  to  the 
dorsum. 

applied,  and  two  days  later  patient  presented  himself 
at  the  Northwestern  University  Surgical  Dispensary 
for  treatment.  There  was  considerable  swelling  of 
the  whole  hand,  but  distinctly  greater  upon  the  radial 
side.  Dorsal  thenar  area  had  slightly  greater  swelling 
present  than  palmar  thenar  area.     Upon  inspection  it 


ABSCESSES  IN  SUBAPONEUROTIC  SI', ICE  2!)o 

was  not  (lidiciill  to  sec  that  the  thenar  area,  as  a  w  hule, 
was  nuicli  more  swollen  than  I  he  remainder  of  the  hand. 
Adduction  thenar  crease  was  the  dividini^  line.  Thnnih 
nietacarj)al  l'ull>'  abducted,  proximal  i)halan.\  senn- 
flexed,  distal  phalanx  fulh'  flexed,  .u:ivini4"  an  almost 
spastic  look  to  the  hand.  The  fin,u,er  phalanges  w'ere 
all  semiflexed.  The  flexion  of  the  index  finger,  how- 
ever, was  more  rigid  than  that  of  the  other  three, 
and  movement  of  it  and  the  thumb  caused  more  pain 
than  of  the  three  ulnar  fingers.  Both  epitrochlear  and 
axillary  glands  slightly  enlarged  and  tender.  Old 
incision  upon  dorsal  thenar  region,  from  which  small 
amount  of  pus  was  exuding.  Temperature,  ioi°;  pulse, 
90.     Tenderness  marked  over  palmar  thenar  area. 

Diagnosis. — Abscess,  thenar  space.  Operation: 
Under  nitrous  oxide  anesthesia  incision  made  into 
thenar  area  at  about  the  same  site  as  the  wound; 
much  pus  evacuated.  Gutta-percha  drainage  estab- 
lished ;  hot,  moist  boric  dressings  applied.  September  7, 
swelling,  almost  subsided,  still  discharge  of  much  pus. 
Temperature,  99°;  pulse,  84.  Treatment  continued. 
Cultures  taken ;  typical  staphylococcus  aureus  colonies, 
methylene  blue  and  Grams  stains;  staphylococcus 
aureus.  September  9,  hand  much  better,  drainage 
removed,  hot  dressings  reapplied.  September  11,  hand 
in  good  condition;  dry  dressings  applied.  Following 
this,  patient  made  a  rapid  recovery.  Seen  July,  1905. 
No  contraction;  function  perfect. 

TECHNIQUE   OF   TREATMENT   OF   ABSCESSES    IN   SUBAPONEU- 
ROTIC SPACE 

If  the  subaponeurotic  space  be  in\ol\ed,  we  should 
remember  that  the  tendons  proper  in  the  lower  part 
of  the  dorsum  overlie  the  metacarpal  bones,  except  the 
tendon  going  to  the  little  finger;  consequenth-  our 
incision  should  lie  over  the  interosseous  space.     More- 


29G        TREATMENT  OF  FASCIAL  SPACE  ABSCESSES 

over,  any  deep  transverse  incision,  if  too  long,  would 
cut  the  tendon,  while  a  simple  longitudinal  incision 
would  tend  to  close.  Therefore,  in  making  our  incision 
and  drainage,  these  two  factors  should  be  taken  into 
consideration  and  an  adequate  opening  provided,  which 
does  not  injure  the  tendon.  Those  cases  complicated 
with  middle  palmar  space  infection  have  already  been 
discussed  (p.  289). 

If  the  infection  has  spread  up  under  the  annular 
ligament  into  the  forearm,  the  pus  will  lie  beneath  the 
tendons  of  the  flexor  profundus  and  upon  the  pronator 
quadratus.  The  best  method  of  emptying  this  abscess 
would  be  to  go  laterally,  just  anterior  to  the  radius  and 
ulna  about  three  inches  from  the  wrist.  A  complete 
description  of  the  method  of  treating  these  cases  will 
be  found  in  Chapter  XXVI. 

AFTER-TREATMENT  IN  FASCIAL  SPACE  ABSCESSES 

After  any  of  these  procedures  the  usual  hot,  moist 
dressings  are  applied  until  we  feel  that  extension  of  the 
process  has  ceased,  when  they  should  be  abandoned, 
since  the  continuation  of  the  enlargement  of  the  vessels 
incident  to  their  use  results  in  increasing  edema  and 
ultimately  lessening  resistance,  owing  to  improper  cir- 
culation; hence  they  become  a  menace  to  the  part 
rather  than  a  help.  At  this  stage  elevation  of  the  part 
will  be  found  to  be  of  material  aid.  Immobilization 
should  be  kept  up  as  long  as  there  is  any  danger  of 
muscular  action  disseminating  the  infection.  As  soon 
as  this  stage  has  passed,  however,  active  and  passive 
movements  should  be  encouraged  at  once,  with  the 
idea  of  assisting  in  the  absorption  of  the  excessive 
edema,  as  well  as  assisting  in  the  prevention  of  tendon 
and  joint  adhesions.  I  frequently  begin  these  on  the 
third  day. 


CHAPTER    X  \'  I  1  I 

PROGNOSIS    AND     RESUME    OF    ACUTE 

SUPPURATIVE  TENOSYNOVITIS  AND 

FASCIAL  SPACE  ABSCESSES 

PROGNOSIS 

The  life  of  the  individual  is  frequently  jeopardized 
in  either  of  these  types  of  infections.  Undoubtedly  if 
proper  treatment  is  instituted  the  danger  will  be 
reduced  to  a  minimum.  The  lymphatic  infections 
which  will  be  discussed  in  the  subsequent  chapters  are 
the  most  frequent  source  of  death.  The  fulminating 
type  of  tendon-sheath  infections  may  cause  death,  but 
the  more  chronic  t^'pe,  as  also  the  fascial  space  abscesses, 
should  have  few  fatalities  except  in  neglected  cases. 
Especial  caution  should  be  exercised  in  giving  a  favor- 
able prognosis  in  the  aged,  since  the  prognosis  grows 
rapidly  worse  after  forty.  The  presence  of  a  nephritis 
is  also  of  serious  import. 

It  is  very  nearly  impossible  to  state  from  a  stud>' 
of  the  literature  what  proportion  of  cases  may  hope  for 
a  satisfactory  local  outcome.  The  authors  base  their 
statistics  upon  different  classifications.  "Good  result" 
is  used  by  some  to  designate  a  recovery  without  loss 
of  any  part  of  the  hand,  with  function  at  the  wrist 
and  in  the  uninvolved  fingers,  w^hile  others  insist  upon  a 
complete  restoration  of  the  function  in  the  finger  as 
well.  It  is  to  be  hoped  that  in  the  future  the  statistics 
may  be  more  accurate.  From  my  personal  experience, 
however,  I  feel  that  the  following  statements  may  be 
made.  A  complete  functionating  hand  can  always  be 
promised  in  acute  infections  of  the  hand,  not  involving 
the  tendon  sheaths,  unless  necrosis  of  tissue  has  taken 


298     TENOSYNOVITIS  AND  FASCIAL  SPACE  ABSCESSES 

place  or  joint  involvement  has  occurred.  That  is  to  say, 
abscesses  of  the  middle  palmar  space,  thenar  space,  and 
forearm,  as  well  as  simpler  conditions,  can  be  treated 
with  a  perfect  functionating  result.  This  has  occurred 
in  my  experience  even  after  four  or  five  weeks  of  in- 
adequate treatment.  In  tendon  sheath  infection,  how- 
ever, the  results  are  not  nearly  so  good.  By  proper 
and  early  treatment  a  perfect  result  can  generally  be 
assured  as  to  function  of  the  wrist-joint,  hand  and 
fingers  not  involved.  Where  the  tendon  sheath  of  a 
finger  is  involved,  unless  early  treatment  is  instituted, 
flexion  of  the  phalanges  of  that  finger  is  likely  to  be 
lost,  while  flexion  at  the  metacarpophalangeal  articu- 
lation may  generally  be  preserved.  In  early  cases  or 
under  exceptional  circumstances  complete  function  may 
be  secured.  In  the  thumb,  even  though  the  function 
of  the  flexor  longus  pollicis  is  lost,  the  hand  will  not 
be  seriously  impaired,  since  the  smaller  muscles  of  the 
thumb  will  give  it  such  function  that  the  impairment 
will  not  be  as  serious  by  any  means  as  in  the  fingers. 
Extension  from  tendon  sheaths  to  the  forearm  should 
be  looked  upon  with  anxiety,  and  if  serious  complica- 
tions or  sequelae  are  present,  the  patient  must  be  warned 
that  the  course  may  be  long  and  the  ultimate  restora- 
tion of  function  depend  much  upon  continued  and  faith- 
ful application  of  after-treatment. 

RESUME 

Success  in  the  treatment  of  tendon-sheath  infections 
of  the  hand  depends  upon  early  accurate  diagnosis, 
upon  incisions  so  made  as  to  drain  the  proper  sites 
without  involving  uninfected  areas,  and  upon  careful 
after-treatment. 

Two  types  must  be  recognized,  the  fulminating  and 
the  subacute.  The  treatment  will  vary  with  the  type. 
The  most  marked  symptoms  and  signs  are:  LocaHzed 


RESUME  290 

cxcruciatinii  tcndcriR'ss  oxer  llic  course  ot  iIk-  ^hcatli, 
pain  on  extension,  espccieilly  at  the  proximal  vnd  of 
the  shealh,  and  the  characU'ristic  posilioii  of  the  Ihi^er. 

rnfecti(jn  fnjin  the  tend(jn  sheath  of  ihe  index 
Ihii^er  will  most  often  extend  to  the  pnjximal  inter- 
jjlialani^eal  joint,  thenar  space,  lumbrical  spaces,  and 
the  surface  at  the  ])n)xiinal  end  of  the  sheath. 

From  the  middle  finger  it  most  often  extends  to  the 
proximal  interi)halangeal  joint,  the  lumbrical  spaces, 
the  surface  at  the  proximal  end,  and  the  middle 
l)almar  space,  although  it  may  invade  the  thenar  space. 

From  the  ring  finger  the  extensions  are  the  same, 
except  that  it  always  involves  the  middle  palmar  space 
if  extension  takes  place  into  the  palm. 

From  the  little  finger,  the  most  common  sites  of 
extension  are  to  the  proximal  interphalangeal  joint 
(not  common),  the  lumbrical  space,  the  middle  palmar 
space,  the  surface  at  the  proximal  end  of  the  sheath, 
and  the  ulnar  bursa.  From  the  ulnar  bursa,  it  may 
extend  to  the  middle  palmar  space,  radial  bursa,  inter- 
osseous space  below^  the  flexor  profundus,  and  the  wrist- 
joint.  From  the  sheath  of  the  flexor  longus  pollicis  to  the 
thenar  space,  ulnar  bursa,  wrist-joint,  and  interosseous 
space  above  described. 

Incisions  should  be  too  radical  rather  than  too 
conservative.  Incisions  arc  best  made  in  the  fingers, 
either  upon  one  or  both  sides  of  the  tendon  sheath 
over  the  length  of  the  shaft  of  the  middle  and  proximal 
phalanx,  avoiding  the  joints,  and  into  the  proximal  end 
of  the  sheaths  or  the  lumbrical  spaces  to  provide  drain- 
age there.  Complete  splitting  along  one  side  should  be 
done  in  case  of  doubt  as  to  the  adequacy  of  drainage 
which  should  be  the  first  requisite. 

The  ulnar  bursa  is  best  treated  b>'  splitting  it 
throughout  its  length,  cutting  upon  the  ulnar  side. 
The  anterior  annular  ligament  may  be  cut  if  necessar\-. 
This  is  commonly  supplemented  by  incisions  upon  the 


300     TENOSYNOVITIS  AND  FASCIAL  SPACE  ABSCESSES 

radial  and  ulnar  sides  of  the  forearm  above  the  wrist- 
joint,  and  on  a  level  with  the  flexor  surface  of  the  bones; 
through-and-through  drainage  is  then  carried  out  under 
the  flexor  profundus  tendons.  An  ulnar  incision  may 
be  sufficient.  If  the  pus  has  invaded  the  forearm,  an 
ulnar  incision  is  made  at  the  middle  of  the  forearm 
between  the  flexor  carpi  ulnaris  and  the  flexor  sublimis, 
or  between  the  flexor  carpi  ulnaris  and  the  ulna. 

Incision  of  the  flexor  longus  pollicis  sheath  is  made 
from  a  finger  breadth  below  the  anterior  annular  liga- 
ment to  the  end  of  the  sheath.  Opening  may  be  made 
above  the  anterior  annular  ligament,  the  upper  half 
of  which  may  be  cut.  However,  drainage  may  be 
better  instituted  above  the  wrist  by  the  lateral  incision 
mentioned  under  ulnar  bursal  infections. 

In  the  after-treatment  the  Bier  constrictor  may  be 
used  for  a  few  hours,  hot,  moist  dressings  for  from  two 
to  four  days,  followed  by  dry  dressings,  the  hand  being 
held  in  overextension  by  splint,  daily  manipulation 
of  joints  and  muscles  after  immediate  danger  of  sys- 
temic infection  has  ended. 

There  may  be  accumulations  of  pus  in  any  of  the 
six  fascial  spaces  I  have  described,  to  the  exclusion  of 
any  or  all  the  others,  namely,  the  middle  palmar, 
thenar,  lumbrical,  hypothenar,  dorsal  subaponeurotic, 
dorsal  subcutaneous.  These  may  be  involved  separately 
or  in  conjunction  with  the  tendon  sheaths.  The 
middle  palmar  space  with  its  diverticula  along  the  three 
lumbrical  muscles  is  best  drained  by  an  incision  along 
a  lumbrical  canal  carried  up  to  the  space.  The  thenar 
space  is  best  drained  by  an  incision  on  the  dorsum  to 
the  radial  side  of  the  index  metacarpal.  Hypothenar 
abscesses  are  localized  and  can  be  drained  by  simple 
incision.  All  forearm  extensions  may  be  drained  by 
lateral  incisions  above  the  wrist,  the  drainage  being 
inserted  under  the  tendons  of  the  flexor  profundus 
digitorum. 


SECTION    III 
LYMPHATIC  INFECTIONS 

CHAPTER    XIX 

THE    RELATION   OF   LYMPHANGITIS   TO 
OTHER  TYPES  OF  INFECTION— DIS- 
CUSSION OF  THE  ANATOMY 

THE  RI':LA'riON  OF  LYMPHANGITIS  TO  OTHER  TYPES  ()]• 

INFECTION 

Lymphangitis  may  be  of  two  types,  superficial  and 
deep.  Of  these,  the  superficial  is  most  common,  owing 
to  the  fact  that  slight  abrasions,  superficial  fissures,  and 
small  i)unctures,  disregarded  by  the  patient  because 
they  are  considered  of  no  importance,  are  generally 
the  source.  These  lie  in  the  superficial  tissues  and  lead 
to  a  superficial  or  subcutaneous  infection.  The  rarer 
type,  deep  lymphangitis,  may  undoubtedly  occur. 
When  it  does,  however,  it  develops  as  a  complicati(Mi 
of  superficial  lymphangitis  or  as  a  sequence  of  deep 
injury,  and  when  such  deep  injury  occurs  the  wound  is 
generally  considerable,  so  that  the  lymphangitis  is  of 
secondary  importance  to  the  local  condition. 

For  the  sake  of  study,  lymphangitis  must  be  sharply 
differentiated  from  tenosynovitis  and  fascial  space  infec- 
tion. It  is  true  that  in  a  large  number  of  cases  a  teno- 
synovitis or  fascial  space  infection  may  develop  from  a 
lymphangitis,  but  it  is  also  true  that  in  a  majority  of 
cases  neither  complication  ensues  unless  ill-advised 
surgcr>'   produces  them,      lender  pathogenesis    I   shall 


302     LYMPHANGITIS  AND  OTHER   TYPES  OF  INFECTION 

discuss  these  complications  in  full,  and  under  symp- 
tomatology shall  try  to  suggest  the  various  points 
which  may  serve  to  differentiate  them  when  they  are 
separate  conditions  or  may  serve  to  diagnosticate  their 
development  when  they  arise  in  the  course  of  a  pure 
lymphatic  infection.  Owing  to  the  intimate  relation 
of  lymphangitis  to  septicemia,  it  has  seemed  wise  to 
associate  the  discussion  of  the  former  with  that  of  the 
latter,  and,  for  the  sake  of  the  clinical  picture,  to  con- 
sider in  relation  to  them  the  various  severe  infections 
jeopardizing  life,  such  as  gas  bacillus  infections  and 
anthrax.  A  complete  discussion  of  tenosynovitis  and 
fascial  space  abscesses  may  be  found  in  the  preceding 
chapters. 

ANATOMY 

In  order  to  understand  the  pathogeny  of  lymphatic 
abscesses,  an  accurate  knowledge  of  the  position  and 
course  of  the  lymphatic  vessels  is  absolutely  essential. 
The  masterful  work  of  Mascagni  and  the  later  work 
by  Sappey  have  been  fully  reviewed  and  verified  by 
Poirier,  with  the  assistance  of  his  pupil  Cuneo,  making 
use  of  Gerota's  process  of  injection,  and  the  following 
is  largely  quoted  from  their  treatise  upon  that  subject. 
We  so  often  see  the  superficial  lymphatics  in  the  course 
of  surgical  practice  that  we  are  inclined  to  forget  that 
there  are  deep  lymphatics  which  follow  the  deeper 
vessels.  Sappey  believed  that  these  two  symptoms 
were  absolutely  independent.  Poirier,  however,  main- 
tains that  communication  is  fairly  common,  especially 
in  the  articular  regions.  It  is  important  to  remember 
that  the  principal  vessels  and  glands  lie  superficial  to 
the  large  veins  and  seldom  deep.  The  clinical  signifi- 
cance of  this  is  apparent  to  the  surgeon.  Another 
general  point  of  importance  is  that  the  texture  of  the 
surrounding  connective  tissue  influences  their  shape  and 


ANATOMY 


303 


nunilici'.      II'  llic  cniincctiNc  tissue  is  lax,  tlicir  Ifiidcncy 
is  to  run   toLii-lluT  and   hcconic  siiuioiis  and   saecilorni 

Fig.  96 


^■(My^ 


?Xr:>;-^:'S' ■ 


Drawing  showing  lymphatics  grouped  aboul  a  hair  tulHcle  on  the  dorsum. 
Character  of  lymphatic  tissue  commonly  seen  in  loose  connective-tissue  spaces. 
(After  Sappey.) 

(Fig-.    96).      C\)nsc(iiK'ntl>-    the    infc-ction    is    likeK'    to 
localize    in    the    looser   connect i\t'-t issue    areas.       This 


304     LYMPHANGITIS  AND  OTHER  TYPES  OF  INFECTION 

probability  is  accentuated  by  the  fact  that  glands, 
either  microscopic  or  macroscopic,  show  a  predilection 
for  these  areas.  The  fact  that  sacciform  dilatations 
and  microscopic  glands  do  occur  explains  the  produc- 
tion of  abscesses  in  the  course  of  an  apparently  un- 
interrupted lymphatic.  Moreover,  the  variability  both 
in  the  number  and  the  position  of  these  glands  renders 
absolute  statements  as  to  their  position  impossible. 
Not  alone  are  microscopic  glands  present  in  the  course 
of  the  vessels;  Gulland  has  demonstrated  them  in 
the  axilla,  and  Stiles  has  seen  axillary  glands  appear 
during  lactation  and  disappear  on  its  cessation.  How- 
ever, this  may  be  stated:  In  a  given  animal  and  a 
given  region  the  quantity  of  glandular  tissue  is  always 
practically  identical.  Thus  if  the  glands  are  small 
they  are  numerous,  and  if  large  they  are  likely  to  be 
scarce.  In  any  case,  however,  they  are  generally 
paravascular. 


The  Lymphatic  Vessels  of  the  Hand  and  Forearm 

These  may  be  divided  into  two  groups — the  super- 
ficial lymphatics,  which  arise  from  the  integument  and 
whose  collecting  trunks  run  in  the  subcutaneous  cel- 
lular tissue,  and  the  deep  lymphatics,  arising  in  the 
deeper  tissues  and  in  vessels  following  the  deep  blood- 
vessels. 

Superficial  Lymphatics 

These,  being  easily  demonstrated  experimentally  and 
seen  so  often  clinically,  are  well  known. 

"The  superficial  lymphatics  come  from  all  parts  of 
the  cutaneous  covering  of  the  limb,  but  it  is  in  the 
fingers  (Fig.  97)  and  the  palm  of  the  hand  that  the 
network  of  origin  is  the  richest.      It  is  therefore  at 


SUPERFICLIL  LYMriLITICS  :iOo 

these  points,  and  more  parlicularK'  on  ihc  i)almar 
surface  of  the  fingers,  that  i)unctures  must  he  made 
for  the  injection  of  the  lymphatics  of  the  upper  limb. 
"The  collecting  trunks  of  the  superficial  network 
appear  at  the  roots  of  the  fingers  and  at  the  base  of 
the  palm  of  the  hand  (Fig.  98).  They  then  run  upward 
on  the  fort'arni  and  arm,  receiving  as  they  ascend  the 
lymph  from  other  parts  of  the  cutaneous  covering. 
The>'  terminate  in  the  glands  of  the  axilla.  We  will 
stud\-  first  their  digital  and  palmar  origin,  and  then 
their  course  and  termination. 

Fig.  97 


mm 


Network  of  lymphatics  on  the  side  of  the  finger.  The  accompanying 
drawing  represents  the  trunklets  which  carry  the  lympliatic  stream  to  the 
base  of  the  finger.     (After  Sappey.) 

"Origins:  {A)  In  the  fingers,  the  network  of  origin 
presents  its  maximum  of  de\elopment  on  the  palmar 
surface  (Fig.  99).  Here  the  meshes  are  so  closely 
set  that  it  is  only  by  a  careful  examination  with  a 
lens  that  they  can  be  distinguished.  The  dorsal  net- 
work is  much  less  rich  than  the  preceding  (Fig.  100). 
From  these  two  networks  arise  a  considerable  number 
of  collectors,  which  con\ergc-  toward  the  sides  ot  the 
fingers  and  unite  to  form  two  or  three  trunks  on  each 
of  these  surfaces  (Fig.  97).  These  trunks  at  first  follow 
20 


306     LYMPHANGITIS  AND  OTHER  TYPES  OF  INFECTION 


Fig.  98 


^:-,\*' 


Showing  lymphatics  of  a  hand  and  arm,  the  areas  of  origin  and  distribution, 

(After  Sappey.) 


SUPERFICIAL  LYMriLlTICS 


•M)l 


Fig.  99 


Showing  extensive  network  of  lympliatic  channels  on  the  pahn  and  fingers, 
with  their  extensions  to  the  dorsum  and  to  the  forearm  through  the  collecting 
trunklets.     (After  Sappey.) 


308     LYMPHANGITIS  AND  OTHER  TYPES  OF  INFECTION 

the  corresponding  collateral  artery,  but,  having  arrived 
at  the  base  of  the  finger,  they   incline  backward  and 


Fig.  100 


Showing  lymphatics  upon  the  dorsum.     Note  how  few   there  are   in    com- 
parison with  those  upon  the  palmar  surface.     (After  Sappey.) 

run  toward  the  interdigital  space.  They  then  pass 
to  the  posterior  surface  of  the  hand,  and  are  directed 
toward   the   wrist,   where   we   shall   trace   them   again 


SI  I'EKl'ICI.II.   I.YMI'II.ITICS 


:\m 


shortly.  hi  I  heir  coiii'sc  on  the  (hjrsal  siirlacc-  ot  llic 
hand  lht\  clfcct  iiimuM-oiis  anastoniost's.  They  cross 
one  another  freciiK'ntI\-,  and  it  is  no  unusual  thing  to 
vSee  a  collecting  trunk,  which  has  arisen,  for  exanijjle, 
in  the  fourth  interdigital  space,  uniting  with  trunks 
which  run  along  the  external  part  of  the  dorsal  surface 
of  the  hand. 

'' {B)  In  the  palm  of  the  hand  the  network  of  origin 
is  also  extremely  rich.  From  this  network  run  nu- 
merous trunklets,  which  we  may  divide  into  external, 
internal,  inferior,  superior,  and  central  (Fig.  loi). 

J'^IG.   101 


Lymphatic  vessels  of  the  palm,  showing  their  extensions  from  all  the 
borders  to  the  dorsum  and  the  extension  from  the  central  portion  into  the 
deep  lymphatic  along  the  palmar  arch.     (After  Sappey.) 

"The  external  trunklets,  four  to  six  in  number,  run 
obliquely  upward  and  outward,  and,  crossing  the  sur- 
face of  the  thenar  eminence  in  a  slanting  direction, 
terminate  in  the  lymphatics  coming  from  the  integu- 
ments of  the  thumb. 

"The  internal  trunklets,  more  numerous  than  the 
preceding  (eight  or  ten),  run  almost  transversely 
inward,  and,  crossing   the   ulnar   border  of   the   hand. 


310     LYMPHANGITIS  AND  OTHER  TYPES  OF  INFECTION 

reach  the  dorsal  surface  and  empty  themselves  into 
the  collecting  trunks  which  arise  from  the  integument 
of  the  little  finger. 

"The  inferior  trunklets,  which  vary  from  twelve  to 
fifteen  in  number,  are  directed  toward  the  interdigital 
spaces;  they  then  reach  the  dorsal  surface  of  the  hand 
and  terminate  in  the  digital  collecting  trunks. 

"The  superior  trunklets  reach  the  anterior  surface 
of  the  wrist,  and  unite  to  form  three  or  four  trunks, 
which  ascend  on  the  anterior  surface  of  the  forearm. 

"The  central  trunklets  run  toward  the  deep  portion. 
They  traverse  the  subcutaneous  fatty  layer  and  the 
superficial  palmar  fascia,  and  they  usually  unite  into 
a  single  trunk.  The  latter,  which  has  been  well 
described  by  Sappey,  takes  the  following  course:  It 
is  directed  immediately  outward,  running  underneath 
the  fascia,  in  front  of  the  flexor  tendons.  It  thus  comes 
to  the  adductor  transversus  pollicis,  crosses  the  inferior 
border  of  this  muscle,  and  then  crosses  the  outer  border 
of  the  first  dorsal  interosseous,  on  the  posterior  surface 
of  which  it  ascends.  It  there  joins  collectors  coming 
from  the  index  finger,  and  in  company  with  the  latter 
reaches  the  dorsal  surface  of  the  wrist. 

"Course:  All  these  collecting  trunks,  which  arise 
from  the  integuments  of  the  fingers  and  hand,  run  in 
the  subcutaneous  cellular  tissue  toward  the  root  of 
the  limb.  They  are  usually  more  superficial  than  the 
veins  whose  trunks  they  cover.  They  diminish  in 
number  as  they  are  traced  upward.  In  the  forearm 
there  are  about  thirty,  but  in  the  middle  of  the  arm 
not  more  than  fifteen  to  eighteen  (Sappey). 

"In  the  wrist  they  are  divided  into  two  groups,  of 
which  one  runs  on  the  dorsal,  the  other  on  the  palmar 
surface  of  this  part  of  the  limb. 

"In  the  forearm  they  tend  to  divide  themselves 
into  three  groups — an  external  group,  which  ascends 


si'/'KRr/c/.i/.  /.}.]//'//. n/cs  ;;ii 

aloiii^'  llu-  icitlial  bortlcr  ol  I  lie  lorcai'in ;  an  iiiLenial 
group,  which  follows  the  uhiar  hcjrder;  a  niiddie  group, 
which  is  a  satellite  of  tlie  nicdiaii  vein  and  runs  i)('tvvcc'n 
the  two  preceding. 

"A  little  below  the  bend  of  the  elbow  the  two  lateral 
groups  come  more  and  more  to  the  anterior  surface 
of  the  limb  and  unite  with  the  median  group;  on  the 
dorsal  surface  we  find  nothing  but  some  rather  small 
collecting  trunks,  which  incline  obliquely,  some  out- 
ward, others  inward,  and  reach  the  anterior  surface  of 
the  arm  (Fig.  98).  At  the  level  of  the  olecranon  these 
collecting  trunks  present  remarkable  sinuosities. 

"  In  the  arm  the  different  collecting  trunks,  hence- 
forth united  into  a  single  bundle,  show  a  tendency  to 
arrange  themselves  on  the  external  surface  of  the  arm, 
parallel  to  each  other. 

"Termination:  The  majority  of  these  collectors  run 
as  far  as  the  neighborhood  of  the  base  of  the  axilla. 
Here,  they  perforate  the  deep  fascia  and  terminate 
in  the  humeral  chain  of  axillary  glands.  The  collectors 
from  the  outermost  and  innermost  parts  have  quite  a 
different  termination;  thus,  two  or  three  of  the  most 
internal  end  in  the  supra-epitrochlear  gland.  We  have 
already  seen  that  the  efferents  of  this  gland  perforated 
the  deep  fascia  in  the  middle  part  of  the  arm  and  end 
in  the  deep  vessels.  When  this  gland  is  absent,  we  ma\- 
nevertheless  see  the  internal  collectors  perforating  the 
fascia  at  the  same  point  to  reach  the  deep  absorbents. 
The  most  external  trunk  is  also  remarkable  for  the 
special  course  it  pursues.  It  separates  itself  from  the 
other  collectors  in  the  region  of  the  humeral  insertion 
of  the  deltoid,  then  ascends  in  the  deltopectoral  groove, 
where  it  may  traverse  one  or  several  glands  which  we 
have  indicated  above.  This  trunk  usuall\-  passes  into 
a  subclavian  gland,  placed  at  the  spot  wlure'  the 
cephalic  joins  the  axillar\-  \ein.      It  ma\'  also  be  seen 


312     LYMPHANGITIS  AND  OTHER  TYPES  OF  INFECTION 

to  pass  above  the  clavicle,  and  to  empty  itself  into  a 
supraclavicular  gland.  This  arrangement,  though 
somewhat  infrequent  (Grossmann  says  38  out  of  100 
cases),  has  been  figured  by  Mascagni.  This  delto- 
pectoral  trunk  is  sometimes  double  and  even  triple." 

Deep  Lymphatics 

"The  deep  lymphatics  follow  the  brachial  artery  and 
its  chief  branches.  There  are  usually  two  lymphatic 
trunks  for  each  artery.  With  Sappey,  we  will  divide 
these  deep  lymphatics  into  radial,  cubital,  posterior 
interosseous,   anterior  interosseous,   and  brachial. 

"The  radial  trunks  arise  from  the  subfascial  portions 
of  the  palm  of  the  hand.  'One  accompanies  the  deep 
palmar  arch,  turns  around  the  head  of  the  first  meta- 
carpal bone,  and  runs  on  the  outer  side  of  the  carpus, 
and  reaches  the  forearm,  where  it  is  situated  on  the 
external  side  of  the  radial  artery;  the  other,  whose 
origin  is  not  so  deep,  follows,  according  to  the  sketch 
left  us  by  Mascagni,  the  course  of  the  radiopalmar 
artery,  and  also  joins  the  forearm,  where  it  is  placed 
on  the  inner  side  of  the  radial.  Both  then  ascend  as 
far  as  the  bend  of  the  elbow,  where  they  anastomose. 
In  their  antibrachial  course  they  traverse  one  or  two 
small  glands,  the  existence  of  which  is  not  constant.' 
(Sappey.) 

"The  ulnar  trunks  are  also  two  in  number.  They 
have  a  separate  origin.  One,  in  fact,  appears  by  the 
side  of  the  superficial  palmar,  while  the  other  is  a 
satellite  of  the  deep  palmar  arch.  They  unite  at  the 
wrist,  just  above  which  they  receive  a  large  affluent 
which  is  a  satellite  of  the  dorsal  branch  of  the  ulnar. 
They  then  run  parallel  to  the  ulnar  vessels  as  far  as 
the  bend  of  the  elbow.  During  their  course  they 
sometimes  present  one  or  more  small  glands. 

"The  posterior  interosseous  trunks,  which  arise  from 


])I:ei'  lymi'Ii  rrics 


?>v.\ 


the  (k'cj)  niiisclcs  ol  (he  lorcaini,  ])(  rlnr.itc  llic  intcr- 
ossi'oiis  iiiciiil)i'aiir  .111(1  llicii  unite  dl  the  hciul  ol  the 
elbow  with  the  preceding  vessels. 

"The  anterior  interosseous  trunks  rollow  the  vessels 
of  tiiis  name,  antl,  after  presenting"  in  their  course  one 
or  two  small  glands,  also  end  in  the  lymphatic  meeting- 
place  at  the  ])end  of  the  elbow. 

Fig.  102 


JS** 


""»*^ 


^-  - 
Showing  Ij'inphatics  about  a  hair  folHcle.     (After  Sappey.) 

"The  humeral  trunks  comprise  all  the  above-men- 
tioned antibrachial  collecting  trunks.  They  vary  from 
two  to  three  in  number.  They  run  by  the  side  of  the 
humeral  vessels,  and  terminate  in  the  humeral  group 
of  the  axillary  glands.  As  we  have  already  seen,  they 
present  in  their  course  some  small  glands  w^hich  appear 
to  be  nearly  always  present.  In  the  middle  part  of 
the  arm  they  collect  the  efferent  vessels  from  the  supra- 
epitrochlear  gland .  They  also  receive  some  small  trunks 
from  the  muscles  of  the  arm." 


CHAPTER    XX 

LYMPHANGITIS— ETIOLOGY,  PATHOGENESIS, 
AND  PATHOLOGY 

PREDISPOSING  AND  ACTIVE  FACTORS  IN  THE  PRODUCTION 
OF  LYMPHANGITIS 

While  a  lymphangitis  may  develop  at  any  time  of 
the  year,  it  is  most  frequently  observed  in  the  fall  and 
winter,  an  observation  that  is  concurred  in  by  all 
authors.  This  may  find  its  cause  in  the  unnatural 
conditions  under  which  workingmen  live  during  the 
colder  months,  at  which  time  they  are  closely  housed, 
with  the  result  that  they  breathe  impure  air,  and  be- 
cause of  this  and  the  lack  of  outdoor  exercise  their 
power  of  resistance  is  reduced.  It  is  possible  that  the 
colder  air  which  contracts  the  superficial  vessels  may 
have  some  bearing  on  the  development  of  the  infections 
by  lessening  the  natural  protection  against  superficial 
injuries. 

The  source  is  most  often  some  slight  puncture,  carry- 
ing bacteria  beneath  the  surface,  or  the  small  cracks 
so  often  found  in  workingmen's  hands,  especially  in 
winter  about  the  calloused  areas,  the  so-called  durillon 
force  of  the  French  authors.  These  are  particularly 
noted  at  the  distal  part  of  the  palm,  where  dirt  incident 
to  the  occupation  is  rubbed  into  the  fissures.  The 
slight  punctures  often  come  from  needles  or  pins,  and 
are  thus  frequently  found  on  the  distal  phalanx,  gen- 
erally being  so  slight  as  to  have  been  forgotten  when 
the  patient  applies  for  treatment.  Again,  we  note  its 
frequency  after  trauma  of  the  nail.  The  patient  gives  a 
history  of  running  a  splinter  under  the  nail,  or  of  some 


F.icroks  i\  I'liE  rkoDi  (:ri()\  of  i.YMriLiNciris    ;;i5 

iiijurN  which  has  caused  a  scparalioii  ol  the  nail  hvjiii 
its  l)c(,l,  wilh  a  siiiah  siil )()ii ychial  hciii()|-|'haL;c,  which 
lias  become  infected. 

\\'h\-  it  is  that  similar  injuries  may  be  followed 
in  one  case  by  severe  I)niphangitis  and  in  another  by 
no  results  is  still  an  unanswered  question.      We  are 

Fig.  103 


Showing  lymphatics  in  the  pahii  of  the  hand.     (After  Sappey.) 

accustomed  to  say  that  the  resistance  of  the  patients 
varies,  and  this  is  undoubtedly  true.  On  the  other  hand, 
every  surgeon  has  seen  many  cases  of  severe  lym- 
phangitis in  patients  of  apparenth  normal  resistance. 
We  cannot  attribute  the  cause  entirely  to  lessened 
resistance.      It  is  jxissible  that  some  bacteria  contain 


316  LYMPH  AN  Gins 

inherent  cytolytic  attributes  which  lessen  the  possi- 
bility of  the  walling-off  process  and  favor  extension. 
Many  investigators  have  studied  the  question  and 
added  individual  facts  to  our  knowledge,  which  is 
inadequate,  however,  for  a  complete  understanding  of 
the  subject.  Canon  showed  that  ligation  of  the  small 
intestine  favored  bacterial  growth  in  the  blood  stream, 
thus  showing  the  importance  of  proper  intestinal  action. 
He  also  thought  that  he  had  demonstrated  that  an 
excessive  acidity  of  the  blood  is  more  favorable  to 
bacterial  growth  than  any  alkalinity.  This,  however, 
has  not  been  verified. 


THE  INFLUENCE  OF  THE  TYPE  OF  GERM 

It  is  probable  that  almost  any  of  the  various  patho- 
genic bacteria  may  give  rise  to  lymphatic  infection. 
In  a  great  majority  of  the  cases,  however,  the  strepto- 
coccus will  be  found  to  be  the  etiological  factor.  The 
virulence  of  both  streptococci  and  staphylococci  varies 
within  wide  limits,  and  even  the  same  organism  may  in 
successive  cultures  or  various  media  change  its  viru- 
lence. Many  attempts  have  been  made  to  classify 
the  bacteria  according  to  their  virulence,  but  without 
success.  On  the  other  hand,  certain  physiological  pro- 
cesses of  bacteria  have  been  studied  which  may  in 
time  lend  some  aid,  and  meanwhile  they  serve  to 
explain  some  of  the  phenomena  noted  in  infections. 
Among  the  most  marked  characteristics  of  severe 
infections  we  have  the  cytolytic  and  hemolytic  func- 
tions. The  semijaundiced  appearance  of  the  severe 
cases  due  to  the  hemolysis  is  a  well-known  picture,  and 
while  most  often  seen  with  streptococcus  infections, 
it  may  also  appear  in  the  staphylococcus  forms  to  a 
marked  degree,  especially  in  the  aureus  infections  and 
to  a  lesser  degree  in  the  albus.    This  staphylohemolysin 


Till-    IXFLUENCE  01'  THE  TYVE  OF  CEKM  VAl 

iiiiist,  h()\V('\  cT,  1)1'  prc'si'iit  in  considcral)!^'  amounts 
hc'lOrc  its  effects  become  apparent  in  man,  since  his 
serum  contains  normally  small  amounts  of  antista- 
ph^lohsin,  as  was  shown  by  Neisscr,  and,  moreover,  if 
the  inoculation  or  infection  begins  slowly,  the  system 
will  develop  larger  amounts. 

This  hemolysis  is  particularly  marked  in  the  strep- 
tococcus infections,  where  the  pasty,  semiyellow  ap- 
l^earance  in  the  fatal  cases  is  almost  constant.  This 
observation  was  discussed  by  Marmorck  in  1895,  but 
attempts  to  classify  the  virulence  of  the  types  in  rela- 
tion to  it  have,  however,  failed,  since  many  avirulent 
forms  possess  the  same  property  as  shown  by  Schott- 
niiillcr.  Fromme  thought  he  could  differentiate  these 
by  attempting  a  culture  on  a  media  of  lecithin  and 
bouillon,  in  that  the  lecithin  would  inhibit  the  growth 
of  the  more  pathogenic  forms,  and  that  through  this 
he  could  prognosticate  the  severity  of  any  infection 
and  thus  take  proper  steps  for  its  cure.  Unfortunately, 
subsequent  investigations  of  Sachs  and  others  have 
dispelled  these  hopes,  and  we  are  no  further  in  our 
knowledge  than  we  were.  Attempts  have  also  been 
made  to  classify-  the  virulence  of  the  streptococci  by 
reference  to  the  length  of  the  chains.  Lingelsheim,  in 
1899,  first  employed  the  terms  streptococcus  ''longus" 
and  "brevis."  The  more  virulent  types  in  man  are 
most  likely  to  be  found  in  the  long  chains.  No  absolute 
dependence,  howexer,  can  be  placed  upon  this  hnding. 
Many  of  tlie  other  types  of  bacteria  may  l)e  found  in 
the  systemic  infections;  even  the  Bacillus  pyocyaneus 
has  been  found  in  a  number  of  cases,  as  instanced  !)>• 
Roberts,  Finkelstein,  and  Brill  and  Libman. 

A  careful  study  of  the  effects  of  combined  bacterial 
infections  is  to  be  desired.  The  effect  of  symbiosis  is 
not  fully  known,  although  it  has  been  hinted  at  by 
various  authors.     The  effect  of  combined  strej^tococcus 


318  LYMPHANGITIS 

and  staphylococcus  involvement  is  of  especial  interest, 
since  we  so  often  see  this  combination.  Fisher  and 
Levy  suggest  that  the  streptococcus  through  its  rapid 
spread  prepares  the  soil  for  the  staphylococcus.  When 
this  occurs  the  prognosis  is  more  grave,  since  the  com- 
bination seems  to  increase  the  virulence  of  the  strepto- 
cocci. I  personally  have  observed  that  such  cases  have 
a  convalescence  prolonged  much  beyond  the  ordinary 
course  seen  in  patients  infected  with  either  separately. 

THE  INFLUENCE  OF  THE  ANATOMY  ON  THE  COURSE 

A  general  rule  which  the  anatomy  emphasizes  is  that 
from  any  given  point  the  superficial  lymphatics  pursue 
the  shortest  course  to  the  dorsum.  An  exception  is 
made  of  the  centre  of  the  palm,  from  which,  as  has 
been  shown,  an  infection  would  tend  to  go  down  to 
the  superficial  palmar  arch.  These  are  rare,  however. 
The  general  rule  of  the  dorsal  extension  explains  the 
frequency  of  great  edema  on  the  back  of  the  hand  in 
all  cases.  As  specific  examples  of  the  importance  of 
this  observation,  those  infections  arising  at  the  distal 
part  of  the  palm  should  be  noted.  Here  the  lymphatics 
first  go  distally,  then  pass  around  the  web  and  on  to 
the  dorsum,  at  which  site  the  swelling  and  redness  are 
seen,  giving  rise  to  the  assumption  on  the  part  of  the 
thoughtless  that  the  infection  is  primarily  there.  This 
is  then  followed  by  unnecessary  and  harmful  incisions. 
A  little  care  would  have  shown  that  the  starting  point 
was  a  slight  fissure  in  the  callus  on  the  flexor  surface, 
and  that  the  dorsal  redness  was  lymphatic  in  nature, 
accompanied  by  an  inflammatory  edema  which  would 
be  harmed  rather  than  helped  by  an  incision.  The  same 
is  true  of  infections  upon  the  ulnar  and  radial  sides  of 
the  palm.  Where  there  is  localized  redness  on  the  dor- 
sum of  the  hand  we  less  often  see  the  dorsal  lines  of 


THE  IMLVKNCE  OF  THE  .IN.ITOMY  OS  THE  COURSE     31 'J 

redness  ruiiniii.u  up  llu'  arm.      Tlicst'  arc  gcncralK'  the 
accompaninu'nt  of  an  absence  of  local  reaction. 

Alonp:  the  course  of  the  lymph  vessels,  particularly 
on  the  dorsum  of  the  hand,  will  be  found  areas  of 
redness  and  edema  about  twice  the  width  of  the  red- 
ness  accompanying;   the   vessels,    ajjpcaring   as   if   the 


Sliuwinj^  lyni])li;itics  in  the  skin  and  iiround  the  nail  in  a  cliild,  aged 
four  years.     (After  Sappey.) 

infection  were  localizing  there  or  as  if  small  abscesses 
wTre  forming.  These  ma}'  then  be  incised  under  that 
assumption.  It  is  doubtless  true  that  in  the  semi-acute 
cases,  or  those  going  on  to  abscess  formation,  the  l()c"ali- 
zing  processes  ma>'  start  from  these  foci,  but  great 
care  should  be  exercised  before  making  this  deduction, 


320  LYMPHANGITIS 

since  these  are  but  the  evidences  of  the  lacunae  men- 
tioned in  the  anatomical  discussion,  and  generally  sub- 
side at  the  same  time  the  inflammation  disappears  from 
the  vessel  proper. 

Attention  should  also  be  drawn  to  the  normal  course 
of  the  vessels,  and  it  should  be  emphasized  that  lym- 
phatic extension  from  the  little  and  ring  finger  takes 
place  through  the  epitrochlear  glands,  then  to  the 
axillary,  while  infections  beginning  in  the  thumb  and 
forefinger  go  to  the  axillary  glands  without  the  inter- 
position of  the  epitrochlear;  hence  systemic  infection  is 
more  easily  engendered,  and,  moreover,  if  the  observer 
were  searching  for  glandular  enlargement  he  would  not 
expect  to  find  it  at  the  elbow  in  these  cases.  Infec- 
tions beginning  in  the  middle  finger  are  of  especial 
interest  in  that  either  the  axilla  or  the  epitrochlear 
glands  may  be  first  involved,  and  in  some  cases  neither 
of  these  areas  may  receive  the  lymphatic  vessels,  since 
they  may  pass  up  over  the  clavicle  and  into  the  sub- 
clavian glands  and  thus  directly  into  the  circulation. 
The  clinical  importance  of  this  lies  in  the  fact  that 
these  infections  may  reach  the  circulation  very  early 
and  because  of  the  rapidity  of  involvement  lead  to 
severe  and  even  fatal  systemic  infection.  I  have  had 
one  case  that  lends  support  to  this  assumption.  There- 
fore one  would  look  with  great  anxiety  upon  severe 
infections  arising  from  the  middle  and  index  fingers. 

In  some  of  the  patients  the  lymphatic  infection 
rapidly  spreads  from  the  lymphatic  vessel  and  extends 
over  the  entire  dorsum  of  the  hand  and  forearm  with 
the  appearance  of  an  erysipelas  without  the  raised 
border.  The  swelling  is  considerable,  the  skin  takes 
on  a  board-like  hardness,  and  vesicles  may  appear  on 
the  surface.  This  may  subside  without  further  trouble, 
but  very  often  the  subcutaneous  tissue  soon  becomes 
involved   and   diffuse   abscess   formation    takes   place. 


'/'///■;  INFLUENCE  OF  T II li  .tN ATOMY  OS  Till-:  COURSE     :V2\ 

These  are  onliiiariU   \  inilciU  cases  and  should  l)c  care- 
tiilh-  walehed  and  the  abscesses  opened. 

There  is  an  intimate  relation  between  the  l>niphaties 
of  the  distal  extremity  and  the  tendon  sheaths.  Of 
this  I  have  no  anatomical  proof,  Init  such  clinical 
evidence  that  there  can  l)e  no  doubt  of  the  association. 


Fig.  105 


-^^ii-_isi>**-' 


Lymphatics  about  one  of  the  palmar  flexion  creases.     (After  Sappey.) 

It  has  been  my  experience  frequently  to  meet  with 
cases  in  patients  with  pin  pricks,  especially  of  the  distal 
phalanx,  which  lead  to  a  typical  lymphangitis  with  a 
red  line  running  up  the  arm,  and  after  a  couple  of  da>'S 
these  would  show  the  typical  evidences  of  tendon- 
sheath  infection  of  the  finger  invohed.  The  distal 
21 


322  LYMPHANGITIS 

phalanx  itself,  the  site  of  the  primary  injury,  would 
show  little  or  no  serious  consequences.  This  will  be 
discussed  more  fully  under  symptomatology. 

If  the  deep  lymphatics  are  involved,  the  course 
naturally  follows  the  course  of  the  veins,  as  has  been 
pointed  out  above.  If  localized  abscesses  develop,  they 
appear  along  the  line  of  these  vessels.  If  it  be  the 
interosseous,  the  abscesses  will  naturally  lie  under 
the  flexor  profundus,  thus  occupying  the  site  I  have 
already  pointed  out  as  that  in  which  the  deep  abscesses 
spreading  from  the  tendon  sheaths  are  always  found. 
In  these  cases  doubtless  the  tendon  sheaths  would  be 
involved  early,  and  then  we  would  have  a  typical 
tendon-sheath  infection. 

If  the  lymphatic  vessels  along  the  radial  and  ulnar 
vessels  are  the  source,  the  abscess  will  naturally  lie 
along  these  vessels.  It  has  not  been  my  experience  to 
meet  with  any  such  cases,  and  I  am  inclined  to  believe 
that  their  occurrence  is  uncommon.  I  have  seen 
abscesses  along  the  brachial  vessels,  however.  In  one 
case  it  developed  as  an  extension  from  a  deep  infection 
of  the  forearm,  and  in  another  as  the  sequel  of  a  typical 
superficial  lymphangitis  of  the  forearm.  It  seemed 
to  me  reasonable  in  this  latter  case  to  ascribe  its 
development  to  suppuration  in  a  lymphatic  gland  lying 
in  juxtaposition  to  the  vessel,  since  we  know  that,  while 
these  glands  ordinarily  lie  at  the  elbow  and  axilla, 
they  may  occur  at  an 3^  part  of  the  lymphatic  stream. 
From  the  very  nature  of  the  cases  we  would  expect 
deep  lymphatic  abscesses  to  be  uncommon. 

SPOROTRICHOSIS 

Certain  cases  in  which  nodules  develop  along  the 
lines  of  the  lymphatics,  giving  rise  to  small  abscess 
formation,  may  cause  confusion  in  that  it  is  possible 


i.YMPii.rric  .msci-ssi-s  323 

lor  us  lo  1ki\ c  in  Iraiiinalic  iiijuriL-s  ol  the  hand  an 
infection  1)\-  sixirotrichosis.  Practiralh  all  of  ihese 
infections  follow  open  wounds.  It  is  lirst  dcscrihcd 
by  Schenck. 

The  disease  seems  fairh'  j)re\alent  in  rural  districts. 
It  is  j)ossil)le  that  some  of  the  rases  have  been  diag- 
nosticated as  tuberculous  lynij)hangitis.  The  organism 
consists  of  a  branching  septate,  coarse  mycelium  from 
which  o\-oid  bodies  develop  by  budding,  either  from 
lateral  or  terminal  filaments  or  from  the  sides  of  the 
threads.    These  ovoid  bodies  are  spores. 

The  condition  is  characterized  by  the  history  of  a 
traumatic  injury,  and  is  accompanied  by  the  develop- 
ment of  one  or  more  sharply  circumscribed  painless 
or  subcutaneous  abscesses  along  the  course  of  the 
lymphatic.  Inflammator}'  manifestations  are  generally 
absent.  The  course  is  extremely  chronic,  lasting  for 
a  number  of  weeks. 

The  treatment  consists  in  thorough!}-  opening  the 
abscesses,  cleansing  them,  and  giving  large  doses  of 
potassium  iodide  internally. 


RELATIONS  OF  LYiMPHATIC  ABSCESSES  STUDIED  BY 
EXPERIMENTAL  INJECTIONS 

In  order  to  study  the  subject,  attemi)ts  were  made 
to  inject  masses  from  given  sites  along  the  \'essels  in 
cadaver  hands.  The  results  did  not  add  much  to  our 
knowledge,  but  I  will  summarize  them  here. 

Report  of  Injections  of  Forearm  Near  the 
Radial  and  I'lnar  \'essels. — Experiment  i. — Can- 
nula passed  through  small  incision  superficial  to  the 
radial  vessels  just  above  the  wrist.  The  mass  was 
injected  with  considerable  force,  and  on  examination 
a  sui)erficial  area  thrrc  inclus  in  K'ngtli  and  one  inch 
in  diameter  was  found  filKd  w  ith  the  inirctt'd  mass. 


324  LYMPHANGITIS 

(Note. — It  is  extremely  difficult  in  injecting  the 
cannula  to  know  just  exactly  the  position  it  occupies.) 

Experiment  2. — Injected  posterior,  i.  e.,  dorsal  to 
the  radial  vessels.  The  mass  spread  upward,  and  in  the 
section  was  found  to  lie  on  the  radial  side  of  the  flexor 
lorigus  pollicis,  tearing  the  muscle  to  a  great  extent 
up  to  its  origin.  The  mass  had  extended  to  the  ulnar 
side  of  this  vessel,  a  small  part  of  it  lying  on  the  radial 
side  between  the  bodies  of  the  flexor  profundus  digi- 
torum  and  flexor  sublimis  digitorum.  The  greater 
portion  had  passed  underneath  the  flexor  profundus 
digitorum  and  filled  up  the  area  between  this  muscle 
and  the  bones  with  the  interosseous  membrane.  It 
had  extended  to  the  ulnar  side,  lying  in  juxtaposition 
to  the  flexor  carpi  ulnaris,  and  at  its  distal  end  came  to 
lie  near  the  surface,  i.  e.,  near  the  ulnar  vessels.  It 
had  extended  distally  between  the  tendons  of  the  flexor 
profundus  digitorum  and  the  pronator  quadratus.  It 
did  not  pass  into  the  hand.  It  had  extended  en  masse 
approximately  to  about  three  inches  below  the  elbow- 
joint,  and  a  small  prolongation  or  isthmus  extended 
along  the  median  nerve  above  the  elbow- joint  for  three 
or  four  inches  into  the  arm,  still  lying  close  to  the 
median  nerve  and  consequently  near  the  brachial 
vessels  and  accompanying  nerves.  (Note. — Out  of  six 
injections  more  or  less  satisfactory,  this  extension  oc- 
curred in  two  cases,  suggesting  why  it  is  that  in  deep 
infections  of  the  forearm,  loss  of  function  of  the  muscles 
is  so  uncommon,  since  both  the  blood  supply  and  the 
nerve  supply  are  impaired.) 

Experiment  3. — Results  practically  the  same  as 
Experiment  2. 

Experiment  4.  —  Results  practically  the  same  as 
Experiment  i. 

Experiment  5. — Mass  lay  to  the  radial  side  of  the 
arm  above  the  flexor  longus  pollicis  and  to  the  radial 
side  of  the  flexor  profundus  digitorum. 


Till-:  p.rriioi.ocY  of  lympilincitis  :;25 

(iKNI<:KAL  (\)N(Ll  SIONS  IN  I  INS  S|<;K1I;S  ()!•  I"..\  I'llK  I - 
MENTS   UPON  Till':   RaDIAL  \'KSSK1.S. — Wc   lia\ C  (Icilloil- 

strated  thai  if  an  abscess  shoiihl  dcxcloi)  alon.u  llu- 
course  of  the  lymphatic  vessels,  lying  in  juxtaposition 
to  the  radial  artery,  it  may  be  a  superfirial  abscess 
which  would  jjoint  on  th(>  radial  side  of  the  arm.  If 
il  follows  the  vessels  farther  it  may  sj)rca(i  to  the  deep 
tissues  of  the  arm.  In  other  words,  it  ma\'  pnjduce 
the  same  result  as  an  extension  alont;  the  interosseous 
vessels  or  a  rupture  from  the  ulnar  or  the  radial  syno- 
vial sheaths.  It  may  extend  to  the  ulnar  side  and  lie 
inuiiediately  under  the  skin. 

Experiments  by  Injection  along  the  Ulnar 
Artery. — As  in  the  injections  along  the  radial  artery, 
these  experiments  are  more  or  less  unsatisfactory  owing 
to  the  fact  that  there  was  always  considerable  doubt 
as  to  the  exact  position  the  tip  of  the  cannula  occupied, 
although  the  intention  w^as  to  inject  as  close  to  the 
ulnar  artery  as  possible,  /.  e.,  to  simulate  the  origin 
of  a  large  abscess  coming  from  the  lymphatics  and 
lying  in  juxtaposition  to  this  vessel. 

In  this  series  live  injections  w^ere  made  at  various 
sites,  and  demonstrated  the  tendency  of  such  accumula- 
tions to  come  to  the  surface  on  the  ulnar  side  early  in 
the  course.  If  the  injection  was  persisted  in,  the  area 
(jf  the  forearm  involved  was  hrst  that  between  the 
flexor  carpi  ulnaris  and  the  flexor  profundus  digitorum; 
then  between  the  superficial  and  deep  flexors,  and  then 
the  area  between  the  deep  flexor  and  the  bone,  i.  e., 
the  typical  deep  abscess  of  the  forearm. 

THE  pathology  OF  LYMPHANGITIS 

The  pathology  of  these  cases  concerns  itself  particu- 
larly with  the  changes  in  the  hniph  \-essels  and  glands, 
and  need  not  be  discussed  in  completeness,  since  the 


326  LYMPHANGITIS 

general  facts  are  well  known.  A  picture  of  the  condi- 
tion found  in  a  typical  case  will  be  as  follows: 

The  local  changes  at  the  site  of  injury  may  be  so 
insignificant  as  to  escape  notice.  The  local  reaction, 
even  in  a  case  that  threatens  lethal  issue,  may  be  noth- 
ing more  than  a  slight  redness  indicative  of  a  hyper- 
emia. There  is  no  hardness  suggestive  of  the  outpour- 
ing of  the  protective  leukocytes  with  the  coagulation 
of  the  lymph  and  blood  elements  about  a  site  of  injury 
and  infection,  as  is  seen  in  the  localized  staphylococcus 
infection,  although  great  pain  may  be  present.  This 
is  particularly  seen  in  the  distal  phalanx,  where  the 
differential  diagnosis  between  this  condition  and  a 
beginning  felon  must  be  made. 

The  lymphatic  vessels  show  grossly  by  their  redness 
the  hyperemia  surrounding  them,  and  a  microscopic 
examination  shows  the  destruction  of  the  endothelium, 
suggesting  a  virulent  poison  or  great  activity  in  over- 
coming the  bacteria.  Adami  has  emphasized  the  im- 
portant part  the  endothelial  cells  play  in  inflammations, 
in  that  they  may  act  as  phagocytes  and  may  undergo 
changes  to  giant  cells  or  other  forms  more  fitted  to 
combat  the  process.  A  cross-section  will  show  these 
changes,  and  in  addition  may  show  the  vessels  filled 
by  a  thrombus  made  up  of  cells  and  bacteria,  and  in 
those  cases  where  the  thrombus  lies  close  to  the  wall 
the  bacteria  may  be  seen  in  that  also.  If  the  vessel 
is  injured  or  cut,  the  bacteria  spread  beyond  the  wall, 
but  in  the  ordinary  simple  case  they  will  be  found  con- 
fined to  the  wall  and  the  lumen.  The  bacteria  do 
not  seem  to  be  in  the  leukocytes  to  any  great  extent, 
but  they  are  so  mixed  together  in  the  thrombus  as  to 
leave  some  doubt  in  my  mind  on  this  point.  At  some 
points  I  have  found  the  thrombus  entirely  free  from 
bacteria,  in  which  case  it  may  be  reasoned  that  the 
toxin  has  produced  the  thrombus  in  advance  of  bac- 


'/•///■;  r.iriioi.ocr  of  lymi'ilixcitis  wil 

It'i'ial  rxtciisioii.  In  >()nic  iiislaiiccs,  in  spite  ol  ihc 
rliaiiLifs  in  llic  Inincn,  the  ncsscI  wall  showed  lilllc 
change.  'I1ie  eiidol  heliinn  was  not  clian.i^ed.  Thei'c* 
were  no  cndotlu'liuni  i^ianL  cells.  The  conneclix'e  tissue 
about  showed  the  evidences  of  inflammation  with 
moderate  round-celled  infiltration,  althouL^h  thi>  did 
not  extend  far  into  the  adjacent  areas.  The  capillaries 
were  engorged  with  blood  for  some  distance,  and  the 
connective  tissue  fibers  were  separated  by  the  serous 
exudate.  If  the  inflammation  is  a  chronic  one,  all 
of  the  changes  incident  to  such  infection  are  seen. 
If  the  vessel  is  cut,  there  is  a  rapid  extension  to  the 
surrounding  tissue,  which  macroscopically  takes  on  the 
ai)pearance  of  an  erysipelas  and  pathologically  shows 
the  inflammatory  changes  associated  with  it.  About  the 
lacunar  the  changes  I  have  just  described  are  most 
marked,  a  much  wider  area  about  them  being  involved. 

The  lymph  glands  show  nothing  difTerent  from  the 
ordinary  picture  seen  in  varying  inflammations  of  their 
structure.  Systemically  in  severe  cases  marked  changes 
in  the  blood  and  various  organs  are  found  which  will 
be  discussed  when  speaking  of  the  fatal  cases. 

In  the  severe  cases  locally  w^e  may  find  that  the 
subcutaneous  tissue  and  even  the  skin  may  become 
gangrenous.  Of  course,  the  former  is  most  common. 
Here  the  abscess  will  form,  and  when  opened  large 
sloughs  of  connective  tissue  may  be  removed  from 
which  the  streptococcus  may  be  secured  in  pure 
culture. 


CHAPTER   XXI 
SYMPTOMS  AND  SIGNS  OF  LYMPHANGITIS 

SYMPTOMS  AND  SIGNS  IN  GENERAL 

A  PATIENT  with  a  lymphangitis  ordinarily  gives  a 
history  of  a  slight  abrasion  or  pin  prick,  which  had  been 
considered  of  no  importance.  Frequently  no  history 
of  injury  can  be  secured.  The  patient  has  noticed  a 
slight  malaise  or  chilly  sensations,  possibly  a  severe 
chill  may  be  noted.  There  may  be  no  local  pain  in  the 
hand  or  arm  and  no  swelling.'  Generally,  however, 
there  is  slight  swelling  accompanied  by  a  dull  pain,  and 
at  times  the  edema  on  the  dorsum  may  become  marked 
and  the  pain  very  severe.-  The  symptoms  and  signs 
bring  the  patient  to  the  physician,  who  finds  in  addition 
to  the  local  condition  a  red  line  running  up  the  forearm 
and  arm  corresponding  to  the  anatomical  distribution 
of  the  lymphatic  vessels  draining  the  area  of  primary 
infection.  There  may  or  may  not  be  tenderness  or 
swelling  in  the  region  of  the  epitrochlear  or  axillary 
glands.  Generally,  however,  after  the  infection  has 
lasted  twenty-four  hours  some  tenderness  and  swelling 
are  found.  The  arm  as  a  whole  may  show  some  slight 
swelling,  although  this  is  generally  absent. 

The  degree  of  systemic  involvement  varies  in  the 
widest  limits.  In  some  cases,  even  early  in  the  course, 
the  patient  will  present  the  evidences  of  severe  toxemia 
with  a  chill  and  high  or  low  temperature,  headache, 
anorexia,  and  prostration.  In  a  majority  of  cases, 
however,  these  severe  symptoms  are  delayed  two  or 
three  days,  even  though  there  may  be  a  severe  onset 
with  a  chill,  temperature,  and  headache. 


TYPES  329 


TYPEvS 


Four  types  may  be  seen. 

Type  I.  Simple  Acute  Lymphangitis. — If  the  pro- 
cess subsides,  the  ])hysician  may  be  surprised  at  the 
rapid  disappearance  of  all  evidences  of  the  infection, 
both  systemic  and  local.  All  objective  evidences  may 
entirely  disappear  in  from  twenty-four  to  forty-eight 
hours.  The  red  line  (;f  lymphatic  inflammation  may 
disappear  over  night  with  slight  tenderness  over  the 
gland  area  persisting  for  a  few  hours  longer. 

Type  II.  Acute  Lymphangitis  with  Minor  Local 
Complications. — In  a  second  group  the  s^^mptoms 
may  subside  more  slowly  and  end  in  a  delayed  resolu- 
tion or  even  abscess  at  the  site  of  inoculation  or  in 
the  gland  area  accompanied  by  mild  systemic  symp- 
toms. 

Type  III.  Acute  Lymphangitis  with  Serious 
Local  Complications. — In  a  third  group  of  cases 
complications  arise  ending  in  tenosynovitis  or  subcu- 
taneous abscesses.  These  cases  are  accompanied  by 
severe  pain  early  in  the  course  and  symptoms  more 
or  less  grave  which  arouse  the  anxiety  of  the  physician, 
first,  as  to  the  possibility  of  death  early  from  systemic 
infection,  and  later,  on  account  of  the  toxemia  associated 
with  the  local  process,  which  heals  slowly  and  threatens 
the  life  of  the  patient  or  raises  the  question  as  to  the 
necessity  for  amputation. 

Type  IV.  Acute  Lymphangitis  with  Systemic 
Involvement. — In  a  fourth  group  the  process  may 
give  rise  at  once  to  most  alarming  systemic  symptoms 
and  with  or  without  local  difficult)-  end  fatalh-  in  a 
few  da>s. 

The  first  and  second  groups  are  easily  classified  and 
understood. 


330  SYMPTOMS  AND  SIGNS  OF  LYMPHANGITIS 

ACUTE  LYMPHANGITIS  WITH  SERIOUS  LOCAL 
COMPLICATIONS 

The  third  type  may  be  a  constant  source  of  anxiety, 
and  the  surgeon  is  often  in  doubt  as  to  the  abiHty  of 
the  patient's  resistance  to  cope  with  the  infection,  and 
he  is  constantly  questioning  the  correctness  of  his 
diagnosis  as  to  the  position  of  pockets  of  pus  and  the 
adequacy  of  his  treatment.  It  may  clear  up  the  picture 
somewhat  to  illustrate  this  by  one  or  two  examples. 

Case  XVIII.— A  patient,  Mr.  L,  W.,  was  seen  by 
me  on  the  second  day  of  his  infection.  He  had  injured 
the  forefinger  of  his  left  hand  with  a  piece  of  fine, 
rusty  wire  which  had  penetrated  the  distal  phalanx 
upon  the  volar  surface.  He  was  complaining  of  severe 
pain  in  the  entire  finger,  but  most  marked  in  the  distal 
phalanx.  An  examination  showed  that  the  entire  finger 
partook  of  a  pinkish  hue,  and  was  somewhat  swollen 
throughout.  The  distal  phalanx,  while  the  most  pain- 
ful and  tender,  lacked  the  induration  characteristic  of 
localized  infection.  A  red  line  ran  up  the  back  of  the 
hand  and  forearm  and  could  be  traced  to  the  axilla, 
where  slightly  tender  glands  could  be  palpated.  He 
was  profoundly  ill,  with  a  temperature  of  104°  to  106°. 

The  proper  procedure  was  considered  to  be  that  of 
applying  a  hot  boric  solution  dressing,  rest  both  local 
and  general,  eliminatives,  and  sedatives.  The  question 
immediately  arises  as  to  the  advisability  of  incising 
the  distal  phalanx.  It  seemed  to  me  that  lacking  the 
induration,  suggestive  of  localized  pus,  the  incision 
would  do  little  good,  and  might  open  new  avenues  for 
absorption.  There  could  have  been  no  question  as  to 
making  incisions  at  other  points.  Upon  the  third  day 
our  conservatism  was  rewarded  by  seeing  the  pain 
disappear  from  the  distal  phalanx  as  well  as  the  red 


I.YMI'II.IXC.rriS   II  IT II    LOCAL  COMI'LlcmrjXS       331 

line  of  1\  iiiplialic  iinoK cmcii I  in  llic  ai'iii.  I'lic  paliciiL 
now  located  and  liniili'd  llu-  U  iKkriicss  to  an  area  over 
the  tendon  sheath  of  the  index  hnj^er.  There  was  not  an 
increase  of  the  swelh'nL; of  the(h"stal  phalanx,  although 
the  fnii^cr  as  a  whole  had  taken  on  the  Kill  ai)pearanre 
characteristic  of  distention  of  the  sheath  with  pus. 
The  tendon  sheath  was  opened  and  the  pus  evacuated, 
folio win^;-  which  the  j)atient  ultimately  recovered  with 
a  preservation  of  the  finger.  It  should  be  noted  that 
no  incision  was  made  into  the  distal  phalanx,  although 
that  was  the  site  of  the  original  pain  and  tenderness. 
Moreover,  ui)on  the  second  day  it  was  certainly  im- 
possible to  make  the  diagnosis  of  tenosynovitis. 

Case  XIX. — Mr.  Geo.  W.  applied  to  the  dispensary 
of  the  Post-Graduate  Hospital  with  a  history  of  having 
had  a  small  cut  upon  the  ulnar  side  of  the  palm.  Sud- 
denly after  three  days  he  suffered  from  a  chill  and  felt 
feverish.  The  hand  began  to  swell,  especially  upon  the 
dorsum.  Upon  examination  the  remains  of  a  small 
cut  could  be  seen  upon  the  palm,  but  there  was  no 
evidence  of  inflammation  about  it.  No  localized  ten- 
derness or  swelling.  The  dorsum  of  the  hand,  especially 
upon  the  ulnar  side,  was  greatly  swollen  and  reddish. 
The  skin  of  the  entire  dorsum  was  red.  There  was  no 
subcutaneous  induration,  and  the  skin  itself,  while  red, 
did  not  have  the  brawny  induration  found  in  erysipelas. 
A  red  line  of  lymphatic  involvement  ran  up  on  the 
dorsum  of  the  forearm,  and  could  be  traced  to  the 
epitrochlear  region  and  then  along  the  inner  side  of 
the  arm  to  the  axilla.  Tender  glands  could  be  palpated 
in  both  regions.     Temperature,  103°;  pulse,  100. 

The  question  arose  whether  or  not  an  incision  should 
be  made  over  the  tender  swollen  dorsum.  It  was 
reasoned  that  this  was  not  indicated,  since  there 
was   no   evidence   of   a   localized   abscess   here   or  of  a 


332  SYMPTOMS  AND  SIGNS  OF  LYMPHANGITIS 

diffuse  phlegmon,  which  at  times  accompanies  erysipe- 
latous infection  in  this  region.  Conservative  treatment 
was  therefore  instituted  with  a  rapid  cessation  of  all 
symptoms  in  the  hand  and  lymphatic  vessels.  How- 
ever, the  tenderness  gradually  increased  in  the  epi- 
trochlear  region,  and  a  redness  which  had  not  been 
present  before  now  appeared.  At  the  end  of  seven  days 
a  suppuration  which  had  had  its  origin  in  the  gland 
here  was  diagnosticated.  Drainage  was  instituted,  with 
complete  recovery  in  a  short  time. 

Phlegmonous  Lymphangitis. — One  of  the  most 
serious  types  is  that  in  which  the  infection  seems  to 
involve  the  skin  of  the  back  of  the  hand  and  forearm 
like  an  erysipelas.  The  toxemia  is  great,  the  forearm 
greatly  swollen,  and  the  board-like  skin  shows  small 
blebs  or  blisters  upon  its  surface.  The  bacteria  soon 
invade  the  subcutaneous  tissue  and  lead  to  a  destruc- 
tion of  areas  of  the  subcutaneous  tissue  en  masse,  thus 
leaving  the  infected  skin  without  proper  blood  supply. 
Consequently,  large  pockets  filled  with  pus  and  semi- 
necrotic  tissue  underlie  the  skin  of  the  dorsum,  which 
itself  soon  becomes  gangrenous  in  spots.  Meanwhile, 
the  patient  is  suffering  from  a  severe  toxemia  or  sepsis. 
The  superficial  veins  may  become  thrombosed  and 
threaten  death  by  acting  as  the  source  of  infection, 
even  though  the  lymphatic  absorption  may  have  ceased. 
The  greatest  care  should  be  exercised  in  differentiating 
this  type  from  the  swollen,  reddened,  edematous  form 
seen  in  ordinary  lymphangitis,  in  which  there  is  no 
induration,  either  of  the  skin  or  subcutaneous  tissue. 

Examples  of  these  types  could  be  multiplied  many 
times  in  my  experience.  The  early  signs  and  symptoms 
very  commonly  point  to  an  entirely  different  area  as 
the  probable  site  of  abscesses  than  the  one  in  which 
it  ultimately  develops,  and  I  wish  to  emphasize,  there- 
fore, that  the  diagnosis   of   the  accumulation   of   pus 


i.YMi'ii,i\(;iTis  iririi  system ic  jnvolvemekt    wwa 

shoukl  1)1'  niack'  (Mi1\-  upon  posilixc  sii;iis.  Alter  once 
localizing',  the  absresses  follow  llic  (Ictinilc  lines  laid 
down  in  the  eliai)lei's  ii|)on  teiiosyiioxit is  and  tascial 
space  infection. 

Thp:  Frequency  of  Localization  in  Lymphatic 
Infection. — The  frequency  with  which  localization 
takes  place  in  lym|)hangitis  is  hard  to  state  accurately. 
In  my  experience  lo  to  15  per  cent,  of  the  cases  would 
probably  be  nearl}^  correct,  and  if  anything  it  would 
be  less  rather  than  more  than  that.  The  sites  of  such 
in\()l\-ement  are  ordinarily  the  tendon  sheaths  of  the 
resj)ecti\e  hnger,  the  dorsum  of  the  hand,  the  dorsum 
of  the  forearm,  the  axilla,  and  the  epitrochlear  region. 
Secondary  to  tendon-sheath  infections  and  deep  in- 
fections of  the  hand,  it  is  common  to  find  a  suljcu- 
taneous  accumulation  of  pus  of  lymphatic  origin  on 
the  flexor  surface  of  the  wrist.  From  these  obser- 
vations it  is  very  evident  that  a  great  majority  of 
the  cases  of  lymphangitis  subside  without  secondary 
abscesses  unless  they  are  engendered  by  ill-advised 
incisions. 

ACUTE    LYMPHANGITIS    WITH    SYSTEMIC    LWOIA'EMEXT 

In  oLU'  classification  we  ha\'e  included  in  this  grouj:) 
those  severe  infections  which  through  systemic  absorp- 
tion or  infection  threaten  or  destroy  the  life  of  the 
individual.  The>'  may  arise  from  any  source  or  in 
any  individual.  They  are  more  likel>'  to  occur  in 
individuals  over  thii;ty-five  years  of  age,  and,  if  fatal, 
within  a  short  time  are  more  inclined  to  follow  infec- 
tions of  the  thumb,  index,  or  middle  hnger.  The  little 
finger  is  the  origin  of  many  fatal  cases,  but  here  the 
lethal  issue  is  often  due  to  infection  through  involve- 
ment of  the  tendon  sheaths  with  improper  drainage. 
In  other  words,  death  is  the  outcome  of  two  t>'pes  of 


334  SYMPTOMS  AND  SIGNS  OF  LYMPHANGITIS 

infections:  (i)  An  acute  type  without  localization  in 
the  hand,  and  (2)  a  severe  type  with  localization,  sub- 
sequent toxemia  from  inadequate  drainage,  and  the 
inability  of  the  patient's  system  to  wall  off  the  infection, 
ending  in  death  from  exhaustion  and  sepsis.  These 
types  will  be  discussed  when  dealing  with  systemic 
infection,  and  we  shall  mention  them  only  briefly  here 
for  the  sake  of  completeness.  The  onset  is  generally 
brusque.  The  patient  suffers  a  chill,  followed  by  a 
high  temperature,  which  later  becomes  lower  as  the 
toxemia  increases.  There  is  little  local  reaction  along 
the  line  of  the  lymphatic  or  other  glandular  region. 
The  prostration  is  profound,  the  headache  severe. 
The  face  becomes  pinched,  the  eyes  roving,  the  pulse 
running,  and  the  patient  is  restless  and  cannot  sleep. 
The  prostration  becomes  greater,  the  pulse  more 
running,  the  temperature  normal,  subnormal,  or  high, 
the  skin  clammy  and  the  nose  cold ;  in  other  words,  the 
typical  picture  of  a  virulent  toxemia.  Meanwhile  the 
physician  looks  on  helplessly,  since  there  is  no  localiza- 
tion which  he  may  attack. 

Deep  Lymphangitis. — The  diagnosis  of  deep  lym- 
phangitis must  often  remain  in  doubt,  since  it  is 
generally  associated  with  a  superficial  inflammation,  at 
times  showing  red  lymphatic  lines,  but  generally  ap- 
pearing as  of  the  erysipelatous  type.  The  whole  arm 
and  forearm  are  swollen  as  if  the  extremity  were  a  sac 
and  the  whole  filled  with  fluid.  It  will  be  noted  that 
this  is  different  from  the  appearance  in  superficial 
lymphangitis,  in  which  the  back  of  the  forearm  is 
swollen  out  of  proportion  to  the  front.  There  is  ten- 
derness early  throughout,  but  most  marked  on  the 
dorsum,  where  the  superficial  lymphatics  are  acutely 
inflamed.  The  patient  is  generally  profoundly  ill 
with  all  the  evidences  of  toxemia.  In  no  case  that  I 
have  had  has  there  been  any  localization  of  pus  about 


l.YMI'II.ISCiriS   ll'ITII  SYsriAIIC  l\  rol.VEMEST     .T)") 

(he  (lccj)cr  jjortioii  ol  the  ann.  In  one  patient  an  ab- 
scess localized  itsell  aloni;  the  radial  ai'ter\  about  two 
inches  above  the  wrist.  This  was  subsequently  drained, 
with  recovery  of  the  i)atient.  1  have  not  seen  any 
cases  w  ith  abscesses  under  the  flexor  profundus  tendons 
which  could  not  be  exj)lained  on  the  assumption  of  an 
extension  trom  a  ruj)tured  tendon  sheath,  allh(Ai,u,h  it 
is  certain  they  arc  possible. 

A  fatal  case  of  deep  lymphangitis  came  under  my 
notice  a  short  time  ago,  in  which  the  patient  made 
a  primary  recovery,  but  died  after  four  weeks  from  a 
pneumonia,  probably  directly  dependent  upon  the 
primary  infection.  Indeed,  these  serious  cases  (jf 
infection  frequently  come  to  a  fatal  issue  because 
of  some  intercurrent  complication,  and  such  should 
always  be  looked  for  and  guarded  against.  A  brief 
resume  of  the  case  will  emphasize  the  clinical  picture. 

Case  XX. — Mr.  J.  R.  D.  (Fig.  io6),  an  employee  of 
the  customs  house,  bruised  the  thumb  of  his  left  hand 
in  getting  off  a  street  car.  As  he  expressed  it,  he  thought 
that  he  had  dislocated  the  thumb.  There  was  some 
primary  swelling.  At  the  end  of  the  third  da\'  there 
was  a  considerable  increase  of  the  swelling,  so  that  the 
whole  thenar  area  was  involved,  and  the  forearm  also 
began  to  increase  in  size.  He  now  consulted  Dr.  J.  J. 
Cole,  with  whom  I  saw  the  patient  in  consultation. 
The  swelling  of  the  thenar  area  was  so  great  as  to 
suggest  the  ballooning  out  seen  in  the  abscesses  of  the 
thenar  space.  The  swelling  was  distincth  an  edema, 
however,  there  being  no  hardness  present.  It  was 
treated  by  hot  boric  dressings.  Within  a  few  hours 
the  whole  arm  was  swollen  and  edematous,  as  much 
upon  its  flexor  as  its  dorsal  surface,  although  the  dor- 
sum showed  some  redness  \\hi(-h  was  not  j^R'stMit  on 
the  flexor  surface.  Deej)  tenderness  could  be  elicited 
on  both  surfaces,  especialh-  owr  the  radial  <n\v.      Wy 


336         SYMPTOMS  AND  SIGNS  OF  LYMPHANGITIS 

the  end  of  the  third  day  the  swelHng  of  the  arm  had 
subsided  to  a  considerable  extent,  and  the  swelling 
of  the  flexor  surface  of  the  forearm  was  distinctly  less. 
The  dorsum,  however,  was  still  swollen,  having  the 
appearance  and  giving  the  same  sense  of  hardness  on 
palpation  as  noted  in  erysipelas.  Incisions  made  upon 
the  dorsum  showed  that  the  subcutaneous  connective 
tissue  was  necrotic  en  masse  and  could  be  removed 
with  the  forceps.  The  whole  dorsum  of  the  forearm 
was  undermined.  Several  incisions  were  made  which 
drained  satisfactorily.      Owing  to  the  large  flaps  of  skin 


Fig.  io6 

^ 

1 

^^^^ 

^^ 

^Hj^' 

^B 

HIHil 

He 

-  %J 

^yjl^B^ 

,,,,  ^_^ 

..,    ■       ,■■  :^m 

H^^^^V 

■■i 

Wb^^ 

^^Mm 

^pi^^E 

w^ 

Photograph  of  the  hand  of  a  patient  with  a  deep  lymphangitis  (phlegmo- 
nous erysipelas).     (See  Case  report  XX.) 

left  without  blood  supply,  in  which  the  vitality  was 
impaired  by  the  infection,  some  areas  of  this  also 
sloughed.  As  the  process  subsided  the  thrombosed 
superficial  veins  could  be  seen  on  the  surface  of  the 
deep  fascia.  The  patient  made  a  rapid  primary  re- 
covery, so  that  he  left  the  hospital  at  the  end  of  eight 
days.  The  local  process,  however,  had  not  entirely 
healed.     Some  slight  toxemia  was  present,  from  which 


LYMPIIANCiriS  If  IT  II  SYSTEMIC  INVOLVEMENT     337 

the  patie'iil  was  slowly  recovering,  when  he  was  siid- 
denh-  overtaken  h>'  a  pneumonia  at  the  end  of  four 
weeks,  and  died  after  three  days.  A  culture  taken  from 
a  blel)  which  had  formed  upon  the  skin  showed  a 
staphylococcus  infection.  In  the  subcutaneous  pus, 
however,  a  pure  culture  of  streptococcus  pyogenes  was 
found,  and  1  believe  that  to  have  been  the  source  of 
the  infection.  Incidentally  this  finding  of  the  staphy- 
lococcus under  the  epidermis  when  the  real  cause  was 
a  streptococcus  emphasizes  the  error  w^hich  is  common 
of  mistaking  the  local  subepidermal  infection  for  the 
primary  cause  when  it  may  be  really  secondary.  Un- 
fortunately, no  postmortem  could  be  secured. 

Systemic  Involvement. — As  a  sequence  of  lym- 
phangitis proper  or  associated  with  other  types  of 
infection  of  the  hand,  systemic  involvement  may  be 
seen.  It  occurs  more  frequently  as  the  age  increases. 
While  deaths  may  occur  at  any  age,  by  far  the  greatest 
number  occur  after  forty-five  years,  and  after  fifty 
years  a  severe  infection  of  the  hand  should  be  looked 
upon  with  anxiety.  It  occurs  most  often  associated 
with  a  streptococcus  infection.  In  one  case,  however, 
that  died  under  my  care,  a  staphylococcus  was  present 
in  the  pus  of  the  primary  abscess  (Case  XXI). 
R\ery  case  showdng  evidence  of  septicemia  should  be 
regarded  as  extremely  grave.  Early  in  the  course  it 
may  be  impossible  to  differentiate  a  septicemia  from 
a  toxemia,  since  they  will  present  the  same  picture 
at  the  onset.  The  temperature  is  often  103°  to  106°; 
the  pulse,  120  to  130.  The  dry  tongue  and  skin;  the 
restless,  roving  eyes;  the  constantly  moving  limbs; 
the  thirst;  scanty  urine;  headache;  sleeplessness;  flushed 
cheek;  damp  brow;  and  the  quivering  nostril,  with  the 
hislorx-  of  c-hilh'  feelings  or  a  chill,  present  a  picture 
known  to  all,  and  earl\-  nia\'  be  present  in  t'ilher  a 
toxemia  or  a  septicemia.     In  a  toxemia,  howe\er,  all 


338         SYMPTOMS  AND  SIGNS  Of  LYMPHANGITIS 

these  symptoms  should  subside  within  three  days  if 
due  to  a  primary  unopened  lymphangitis  or  if  it  follows 
the  opening  of  an  abscess  or  a  tenosynovitis.  If,  in- 
stead of  subsiding,  the  symptoms  grow  more  severe, 
it  is  probable  a  systemic  infection  is  present  if  the 
local  pockets  of  infection  have  been  drained.  The 
temperature  generally  continues  high  until  death,  but 
may  become  remittent,  showing  chills  from  time  to 
time  or  symptoms  and  signs  incident  to  complications, 
such  as  bronchitis,  pneumonia,  pleurisy,  lung  abscess, 
metastatic  abscesses,  and  tenosynovitis,  especially  of 
the  extensor  tendon  of  the  great  toe,  in  my  experience. 
The  eye  muscles  may  become  paralyzed  (Tornier) . 
Almost  all  cases  die  when  these  severe  symptoms 
develop.  Death  comes  on  with  the  patient  in  coma  or 
delirium.  Should  the  patient  recover,  the  evidences 
of  toxemia  gradually  subside  and  the  local  wound 
begins  to  show  evidences  of  repair.  The  condition  of 
the  local  wound  as  to  repair  is  of  considerable  prognostic 
importance.  When  a  wound  does  not  heal  as  rapidly 
as  it  should  after  opening,  exceptional  care  as  to  the 
systemic  treatment  should  be  used. 

A  fatal  case  following  a  simple  middle  palmar  abscess 
which  had  been  undiagnosticated  was  referred  to  me  and 
is  worth  reporting,  since  it  illustrates  the  picture  in  the 
septic  cases. 

Case  XXI.  —  Mr.  R.  K.,  aged  sixty-five  years, 
admitted  to  the  hospital  January  23,  1909.  Died, 
February  i,  1909. 

The  history  as  recorded  is  very  meager.  He  stated 
that  he  hurt  his  hand  rubbing  meat  and  getting  some 
brine  in  the  scratches  about  a  month  previous  to 
entrance,  December  22,  1908.  Following  this  his  hand 
was  swollen  and  painful.  Several  incisions  had  been 
made  on  the  dorsum.  On  examination  the  right  hand 
was  found  to  be  swollen,  with  the  palm  bulging.     The 


LYMPHANGITIS  11171/  SYSTEMIC  INroiJ'EMKNT     339 

tingers  were  slightly  restricted  in  motion.  Little  re- 
striction of  motion  at  the  wrist  and  little  swelling  of 
the  forearm.  Systemically  the  patient  showed  xhv 
results  of  toxemia,  being  pale,  weak,  and  emaciated, 
with  the  hunted  look  characteristic  of  these  cases. 
The  urine  showed  a  si)ecific  gravity  of  1020,  was  scanty 
in  amount,  but  contained  no  albumin.  There  were, 
however,  many  hyaline  and  granular  casts,  both  broad 
and  narrow.  A  diagnosis  of  a  middle  palmar  abscess 
was  made,  associated  with  a  toxemia  of  a  high  grade, 
or  a  sepsis,  and  in  addition  a  nephritis. 

In  view  of  these  findings  and  the  man's  age,  a  poor 
prognosis  was  given.  Operation:  Under  nitrous  oxide 
anesthesia,  a  Bier  constrictor  was  applied  and  about  a 
half-pint  of  thick,  creamy  pus  was  evacuated  from  the 
middle  palmar  space.  There  was  no  pus  in  the  thenar 
space  or  the  tendon  sheaths. 

Following  the  operation  the  temperature  varied  from 
99°  to  101°;  pulse,  84  to  100.  During  the  second  day 
it  is  noted  on  the  history  sheet:  "Patient  removed  Bier 
constrictor  during  night,  has  involuntary  urination. 
Hand  and  forearm  violently  inflamed,  arm  not  involved. 
Am  not  sure  whether  mental  symptoms  are  due  to 
kidneys  or  hand." 

That  night  the  temperature  rose  to  102°,  but  varied 
from  this  to  normal  during  the  next  day.  The  pulse 
averaged  100.  During  the  fourth  day  the  temperature 
varied  from  normal  to  100°.  The  pulse  was  still  not 
rapid,  although  the  patient  was  delirious  and  there  was 
evidently  a  metastatic  infection  in  the  tendon  sheath 
of  the  extensor  hallucis  of  right  leg.  Operation,  Janu- 
ary 29,  1909.  Incision  in  palm  enlarged  and  incision 
on  lateral  surface  of  forearm  to  secure  drainage.  Con- 
siderable pus  evacuated.  Incision  over  right  fibula 
near  ankle  and  into  tendon  sheath  of  extensor  hallucis. 
Watery  pus  e\acuated. 


340  SYMPTOMS  AND  SIGNS  OF  LYMPHANGITIS 

The  pulse  and  temperature  ran  about  the  same  as 
before.  The  highest  pulse  recorded  is  120,  and  the 
highest  temperature,  101.4°.  The  mental  condition 
grew  worse,  and  the  patient  died  two  days  later. 

Another  fatal  case,  which  I  saw  in  consultation  with 
Dr.  A.  B.  Eustace,  to  whom  I  am  indebted  for  the 
history  and  report  of  the  findings  at  postmortem, 
at  which  I  was  permitted  to  be  present  through  the 
courtesy  of  Dr.  W.  H.  Hunter  and  Dr.  Eustace,  is  a 
very  valuable  one,  since  the  positions  of  pus  shown  at 
the  postmortem  fully  corroborate  the  findings  which 
I  have  noted  clinically  in  the  cases  which  recovered, 
as  well  as  verify  the  results  which  I  obtained  experi- 
mentally by  injections  of  the  forearm.  It  emphasizes 
also  the  difiiculty  of  differentiating  these  cases  at  times 
from  rheumatism.  Unfortunately,  I  have  not  the  exact 
age,  but  the  patient  was  in  the  neighborhood  of  fifty 
years,  which  again  draws  attention  to  the  influence 
of  age  in  these  fatalities. 

Here  the  primary  focus  was  in  the  ulnar  bursa. 
Owing  to  the  difficulty  of  diagnosis,  the  diagnosis  and, 
consequently,  the  proper  treatment  were  held  in  abey- 
ance several  days. 

Case  XXH. — Miss  E.  J.,  Cook  County  Hospital. 
Patient  entered  on  June  i,  1908.  Attending  surgeon, 
Dr.  E.  Wyllys  Andrews ;  house  physicians,  Drs.  Eustace 
and  Courtenay. 

History  of  present  trouble:  Patient  enters  hospital 
complaining  of  pain  and  swelling  in  right  wrist  and  hand. 
Upon  questioning  she  says  she  awoke  last  Friday  night 
with  pain  in  this  joint.  There  was  a  sense  of  heat  and 
the  joint  was  particularly  painful  on  motion.  Her  sleep 
was  disturbed,  and  by  the  next  morning  she  says  her 
wrist  was  notably  swollen  and  red.  Tenderness  was 
pronounced  over  the  end  of  the  ulna  posteriorly,  and 


LYMI'II.IXC.ITIS   iriTII  SYSTI'.MIC  I  \  lO  UliM  EXT     .".11 

also  aiilcrioi'lx  oxer  holli  hoiics  ol  llic  loicaiin  al  llicir 
cai'pal  ai'liciilal  ion. 

A  histor>'  of  any  prcx  ions  injury,  fall,  iiifctlion,  ov 
arthritis  of  any  sort  is  denied.  Arronii)anyinL;  this 
the  patient  denies  other  symptoms  of  any  sort,  but 
since  Friday  the  joint  has  become  swollen  and  j^ro- 
gressively  worse,  the  pain  is  agonizing,  and  there  is 
an  indefinite  history  of  chills  and  fever. 

Previous  illnesses:  For  the  past  ten  years  she  has 
suffered  intermittently  from  articular  rheumatism,  and 
three  wrecks  ago  she  was  a  patient  in  this  institution 
for  otitis  media  and  discharged  after  a  period  of  two 
weeks'  treatment. 

Physical  examination:  Negative  except  as  follows: 
The  right  wrist  and  hand  are  greatly  swollen  and  in- 
flamed, the  wrist  on  both  surfaces,  the  hand  on  the 
posterior  surface  only.  The  swelling  is  localized  to  the 
wrist  joint  and  extends  up  the  forearm  for  about  three 
inches.  The  fingers  are  in  semiflexion,  and  the  slightest 
movement  causes  extreme  pain.  There  is  also  extreme 
tenderness  around  the  wrist-joint,  which  is  also  very 
painful  upon  motion.  Lymphatic  involvement  is  lack- 
ing, and  apparently  there  is  no  tendon-sheath  involve- 
ment. No  atrium  of  infection  can  be  found,  and  shoulder 
and  elbow-joints  are  not  involved.  The  left  arm  is  not 
involved,  though  some  pain  is  elicited  on  motion  of 
shoulder.  Fingers  give  evidence  of  a  rheumatic 
diathesis  (G.  T.  Courtenay). 


Pulse.     Temperature. 

Respiration.s. 

June  2,  1908  ....         94                102° 

24 

June  2,  1908  ....        103                102° 

24 

June  2,  1908  ....       104               101° 

22 

hite  blood  count  on  entrance,  8200. 

Patient  given 

large  doses  of  sodium  salicylate. 

Operation,  June  4,  1908.  Incision  down  to  ulnar 
bursa  and  one  above  the  anterior  annular  ligament 
on  ulnar  side.    A  hemostat  was  forced  through  to  the 


342         SYMPTOMS  AND  SIGNS  OF  LYMPHANGITIS 

radial  side  and  pus  evacuated.  Gauze  drainage  and 
hot  boric  dressings.  Bier's  constrictor  applied  to  arm 
(A.  B.  Eustace). 

Operation,  June  7,  1908.  Two  incisions  on  the  flexor 
surface  of  the  forearm  just  above  the  wrist-joint  and 
another  three  inches  above  this.  These  were  each  one 
inch  long  and  penetrated  to  the  flexor  tendons;  openings 
connected  with  gauze  drainage  (G.  T.  Courtenay). 

Operation,  June  15,  1908.  Incision  along  ulnar  bursa 
enlarged  and  a  large  amount  of  pus  evacuated.  Knee- 
joint  aspirated  and  pus  obtained.  Two  per  cent,  solu- 
tion of  formalin  in  glycerin  injected.  Died  June  16, 
1908.  Autopsy  by  Dr.  A.  B.  Eustace  and  Dr.  Allen 
B.  Kanavel. 

Hand  and  Arm:  Extensor  surface:  On  opening  back 
of  forearm  a  small  focus  of  pus  is  found  at  junction 
of  lower  quarters  of  forearm.  This  communicates  with 
incision  in  skin  on  side.  There  was  no  pus  between 
extensor  communis  and  deeper  tissues,  except  at  point 
indicated,  and  this  pus  extended  down  underneath  this 
muscle. 

No  pus  found  subcutaneously  on  the  dorsum  of 
the  hand  except  at  the  wrist-joint,  and  this  could  be 
traced  into  the  tendon  sheath  of  the  extensor  communis 
digitorum.  The  tendon  sheaths  of  the  extensor  radialis 
longior  and  brevior  also  showed  pus.  The  tendon  of 
the  extensor  carpi  ulnaris  was  free  from  pus. 

Back  of  the  sheath  of  the  extensor  communis  digi- 
torum is  seen  an  opening  extending  down  to  the  carpal 
bones.  Articulation  between  the  carpal  bones  and  the 
radius  found  to  contain  a  slight  amount  of  pus.  Articu- 
lation between  proximal  and  distal  row  of  bones  also 
contains  a  slight  amount  of  pus.  No  pus  found  under 
tendons  on  the  back  of  the  hand,  communicating  with 
joint. 

Flexor  surface:  Incision  found  in  median  line,  at 
junction    of   lower    and    middle    thirds    through    skin 


i.YMrii.isc.iTJs  II  irii  sYsri'.MK:  i\ loi.ri-.Miisr    '.\V.\ 

imiiU'(Iiatc'l\  al)()\f  .miuilar  linaiiiciil ,  and  on  cilhcr 
side  at  and  ahoxi'  arliciilai-  surface. 

Incision  on  ulnar  side  cxLcnded  upward  for  a  dis- 
tance of  two  and  one-half  inches.  Incision  also  in 
palm  of  hand  on  ulnar  side  lengthwise  along  inner 
edge  of  hypothenar  eminence.  The  hand  as  a  whole 
does  not  appear  to  be  greatly  swollen,  and  sf^ne  con- 
cavity appears  in  the  middle  of  the  palm. 

Upon  opening  the  palm  of  the  hand,  ulnar  l)ursa 
found  to  be  filled  with  pus  and  tendon  sheath  of  little 
finger  also  filled  with  pus.  Rupture  had  occurred  into 
the  forearm  at  a  point  one  and  one-half  inches  above 
the  articular  surface  of  the  wrist-joint.  Middle  palmar 
space  opened  and  found  to  be  filled  with  pus.  Thenar 
space  free  from  pus.  Tendon  sheath  of  flexor  longus 
pollicis  free  from  pus.  Radial  bursa,  no  pus  found  at 
any  point.  Above  the  wTist-joint,  pus  is  found  in 
sheath  passing  up  underneath  tendons  from  mid- 
palmar  space. 

Forearm:  Pus  is  found  underneath  the  flexor  pro- 
fundus digitorum.  Pus  extended  up  the  forearm  in 
juxtaposition  to  ulna  up  to  the  elbow^  lying  immediately 
on  the  ulna. 

Pus  also  found  along  ulnar  arterx'  for  a  distance  of 
about  one  and  one-half  inches  at  middle  of  forearm, 
but  did  not  extend  up  to  the  elbow.  A  small  opening 
is  discernible  at  lower  end  of  ulna  connecting  joint 
with  ulnar  bursa.  It  could  not  be  determined  definitely 
whether  this  opening  was  made  by  dissection  or  was 
present  before. 

No  opening  w^as  demonstrable  between  wrist-joint 
and  radial  bursa. 

No  necrosis  of  bones  of  wTist-joint;  tendon  sheath  of 
ring  finger  intact;  tendon  sheath  of  middle  finger 
intact;  tendon  sheath  of  index  finger  intact.  Pus 
extended  out  in  little  finger  to  proximal  interphalangeal 
joint.     Periosteum  of  radius  and  ulna  not  destroyed. 


344  SYMPTOMS  AND  SIGNS  OF  LYMPHANGITIS 

No  pus  in  elbow-joint.  Axillary  glands  barely  pal- 
pable. 

Heart:     No  evidence  of  pericarditis  or  adhesions. 

Pleural  cavities:  Left,  no  adhesions;  right,  few  ad- 
hesions at  apex. 

Lungs:  Left,  crepitates,  no  consolidation,  frothy  red 
serum  exudes,  apparently  normal;  right,  answers  above 
description. 

Liver:  Gall-bladder  distended  and  filled  with  fluid. 
Liver  is  mottled  on  cut  sections,  the  interlobular  mark- 
ings faint,  no  evidence  of  miliary  abscesses.  Tissues 
very  soft  and  friable  and  color  is  paler  than  normal. 

Spleen:  Enlarged  in  size,  is  soft  and  friable.  Cuts 
like  butter.     Miliary  abscesses  found. 

Kidneys:  Soft  and  friable.  Capsules  strip  with 
some  difficulty  and  leave  parts  of  the  cortex.  Cortex 
is  almost  obliterated,  as  also  are  the  pyramids,  but  here 
and  there  a  distinct  outline  of  a  pyramid  may  be  found. 

Right  knee-joint:  Filled  with  thick  yellow  pus, 
small  ecchymotic  areas  in  periosteum. 

Cultures  before  and  after  death  showed  staphylo- 
coccus albus. 

Microscopic  examination  of  the  various  organs 
showed  acute  parenchymatous  degeneration. 

Postmortem  Statistics. — Tornier  reports  lo  fatal 
cases  upon  which  postmortem  had  been  made.  The 
findings  were  as  follows: 

Cases. 

Acute  hyperplasia  of  spleen     .      .      .     ' 9 

Parenchymatous  nephritis 7 

Bronchopneumonia       . 5 

Lung  abscesses 2 

Empyema 2 

Acute  pericarditis i 

Hemorrhagic  pleuritis i 

Subpericardial,  subpleural,  and  cecal  hemorrhages  ....  4 

Abscess  of  kidney 2 

Abscess  of  liver 2 

Thrombosis  of  veins 2 

Icterus     3 


D'Mr/f./xcr/'fs  inn  I  systi'.mk:  isiolvement    ?Ab 

The  ;ij;c  ol  \.\w  lalal  cases  iiNcragcd  foi'ly-llircc  and 
ciiihl-lciidis  }-ears. 

Thrombophlebitis. — Either  associated  with  lym- 
phangitis or  as  a  distinct  process  we  may  have  thrombo- 
phlebitis. The  symptoms  and  signs  here  would  be  the 
same  as  those  occurring  with  thrombophlebitis  of  the 
leg,  where  it  is  more  common.  Generally  beginning 
with  a  localized  infection,  the  process  extends  into  a 
vein.  The  severity  of  the  symptoms  depends  upon  the 
extent  of  the  process,  varying  from  those  of  a  mild 

Fig.  107 


Photograph  of  a  hand  of  a  patient  with  thrombophlebitis.     Wound  is  left 
open,  as  is  seen  in  photograph.       (Case  XXIII.) 

septicemia  with  localized  evidences  to  most  severe 
toxemia,  metastatic  abscesses,  and  death.  This  can 
best  be  illustrated  by  a  case  which  came  under  my  care 
at  the  Post-Graduate  Hospital. 

Case  XXIII. — Mr.  L.,  aged  twenty-five  years. 
Post-Graduate   Hospital,    March   5,    1909    (Fig.    107). 

Diagnosis. — Suppurative  phlebitis  of  veins  of  dorsum 
of  hand. 

The  patient  applied  to  the  hospital  with  a  small 
infection  upon  the  dorsum  of  the  hand,  apparently 
carbuncular  in  nature.    The  infection  had  been  present 


346  SYMPTOMS  AND  SIGNS  OF  LYMPHANGITIS 

for  four  days,  and  was  gradually  increasing  in  size. 
The  hand  was  considerably  swollen,  and  there  u^as  an 
area  of  swelling  and  induration  extending  up  the  dor- 
sum of  the  forearm  for  three  inches.  Temperature, 
101°;  pulse,  94;  urine  negative. 

Operation. — Gas  anesthesia.  A  crucial  incision  was 
made  over  the  area  and  an  accumulation  of  thick  pus 
and  seminecrotic  tissue  evacuated.  The  indurated 
area  extending  up  the  dorsum  of  the  forearm  was  found 
to  be  a  large  vein  which  was  filled  with  a  septic  throm- 
bus. This  was  opened  for  four  inches  up  on  the  area, 
when  a  free  regurgitation  of  venous  blood  was  secured. 
The  vessel  was  tied  and  the  wound  left  open  (Fig.  107). 
A  Bier  constrictor  was  applied. 

Following  the  operation  the  local  area  granulated 
freely,  and  rapidly  went  on  to  complete  repair.  Over 
a  period  of  four  weeks,  however,  the  patient  developed 
three  metastatic  abscesses  in  various  parts  of  the  body, 
which  were  opened.  Fortunately,  none  developed  in 
the  bones  or  viscera,  at  least,  so  far  as  was  discovered. 
The  temperature  and  pulse  were  never  high,  but  still 
fluctuated  with  the  development  of  the  foci.  The 
patient  ultimately  made  a  complete  recovery. 


CHAPTER    XX  11 

PROGNOSIS  IN  LYMPHATIC  INFECTIONS 

The  prognosis  as  to  life  in  lymphatic  infections  is 
dependent  uj^on  so  many  factors  over  which  we  have 
no  control  that  it  is  extremely  difficult  to  arrive  at  any 
satisfactory  statement  concerning  it.  In  Helferich's 
clinic,  in  a  series  of  nearly  200  severe  infections  of  the 
hand,  a  fatal  issue  followed  in  22  j^er  cent.  These 
statistics  comprise  all  types  of  infection  of  the  hand, 
and  are  limited  to  extensive  abscesses,  tenosynovitis, 
and  severe  lymphangitis.  This  percentage  is  certainly 
high  for  patients  in  the  ordinary  walks  of  life. 

Of  the  factors  concerned,  of  chief  importance  is  the 
age  of  the  individual.  The  average  age  of  fatal  cases 
is  in  the  neighborhood  of  forty-five  years.  The  general 
state  of  the  patient's  resistance  is  of  importance.  For 
instance,  in  Cook  County  Hospital,  where  the  social 
derelicts  are  found,  the  mortality  is  much  higher  than 
in  private  hospitals.  The  presence  of  nephritis  in  the 
various  forms  or  of  any  of  the  chronic  system  diseases 
has  a  marked  influence  upon  the  prognosis. 

If  the  symptoms  of  toxemia  do  not  subside  within 
three  days,  if  no  local  process  has  developed,  or  within 
two  days  after  opening  such  foci,  anxiety  should  be 
felt  for  the  patient.  Either  there  is  a  local  extension, 
or  the  patient  is  not  reacting.  The  part  affected  has 
some  influence  upon  the  prognosis.  The  presence  of 
an  infection  beginning  in  the  little  finger  or  the  thumb 
causes  fear  of  tenosynovitis  with  a  prolonged  con- 
valescence, while  an  involvement  of  the  index  or  middle* 
finger  may  lead  to  severe  systemic  symptoms  earh'. 
The  type  of  germ  in  a  given  patient  is  also  of  great 
importance  from  a  prognostic  standpoint,   since  it  is 


34S  PROGNOSIS  IN  LYMPHATIC  INFECTIONS 

well  known  that  the  gravest  infections  arise  from  the 
streptococcus  and  certain  of  the  gas  bacilli.  Again, 
a  brusque  onset  with  high  temperature  and  chills 
speaks  for  a  serious  infection. 

To  my  mind  the  prognosis  is  influenced  somewhat 
by  the  character  of  treatment.  If  ill-advised  and  pre- 
mature incisions  are  made,  what  might  have  been  a 
moderate  infection  may  be  turned  into  a  severe  type. 
Many  attempts  have  been  made  to  secure  data  upon 
which  prognosis  may  be  made  by  an  examination  of 
the  blood,  and  this  is  of  some  general  value.  One 
of  the  latest  and  most  complete  researches  is  that  of 
Zangmeister.^ 

The  first  conclusion  which  the  author  derived  from 
a  large  series  of  blood  counts  was  that  the  numeric 
fluctuations  of  the  single  leukocyte  forms  per  cubic 
centimeter  of  blood  show  the  real  condition  of  the 
patient,  but  not  the  numerical  ratio  of  the  variety  of 
forms  to  each  other.  To  make  a  prognosis  in  strepto- 
coccus infections  from  the  blood  picture  it  is  important 
to  know  that  the  conditions  change  completely  after 
the  first  twenty-four  hours  after  the  infection,  and  that 
the  findings  during  the  first  twenty-four  hours  do  not 
apply  later  on. 

In  monkeys  he  found  the  following  after  the  first 
twenty-four  hours  after  infection : 

1.  In  infections  rapidly  fatal,  all  forms  of  leukocytes 
decline  quickly  in  number. 

2.  In  infections  fatal  after  a  few  days  he  found  a 
tardy  and  small  increase  of  the  mononuclear  neutro- 
philic cells  and  a  decrease  of  the  polynuclear  neutro- 
philic and  eosinophilic  cells  and  lymphocytes  in  the 
first  eighteen  hours. 

3.  In  infections  not  fatal  he  found  an  increase  of 
the  mononuclear  neutrophilic  cells  during  the  first  six 

1  Monatsschrift  f.  Geb.  und  Gynak.,  Band  xxxi,  Heft  i. 


PROGNOSIS  IN  LYMPII.rnC  INFECTIONS  349 

hours  alter  the  inicctioii ;  Ironi   then  a  (Iccrcasc.       I'hc 
polynuclear   and    eosinophilic    cells   and    l\ni[)h(jcytes 
increase  in  number  after  the  first  six  hours. 
Therefore  good  prognostic  symptoms  are: 

(a)  An  immediate  increase  of  the  mononuclear  neutro- 
philic cells  for  the  first  six  or  eight  hours,  with  a  folhnv- 
ing  decline. 

(b)  An  increase  of  the  polynuclear  cells  after  six  hours, 
after  a  short  decline. 

(c)  An  increase  of  the  eosinophilic  cells  inside  the 
first  twenty-four  hours. 

(d)  An  increase  of  the  lymphocytes  in  the  first 
twenty-four  hours. 

The  prognosis  is  bad  (i)  if  the  mononuclear  cells 
show  no  increase  or  a  decrease  in  the  first  eight  hours; 
(2)  if  there  is  a  continuous  decrease  of  the  polynuclear 
cells  and  lymphocytes. 

In  a  large  series  of  the  blood  countings  before  and 
immediately  after  operations,  the  author  found  that 
these  findings  in  monkeys  are  parallel  to  those  in  man. 

After  the  first  twenty-four  hours  conditions  are 
changed,  and  the  curve  of  the  eosinophilic  cells,  of  the 
lymphocytes,  and  of  the  mononuclear  neutrophilic 
cells  is  of  no  importance.  A  continuous  decrease  of 
the  polynuclear  cells  or  their  remaining  stationary  is 
a  bad  prognostic  sign.  In  less  severe  infections  they 
will  rapidly  or  at  least  slowly  increase. 

His  final  conclusions  are: 

"We  are  allowed  to  make  a  good  prognosis  inside  the 
first  twenty-four  hours  after  the  infection  if  we  find 

(a)  an  immediate  increase  of  the  mononuclear  neutro- 
philic  cells   with    a   slow   decrease   after   eight   hours; 

(b)  an  increase  of  the  polynuclear  cells  after  eight  hours 
after  a  small  decrease. 

"We  have  to  deal  with  a  fatal  infection  (a)  if  the 
mononuclear  cells  increase  after  the  first  twenty  hours; 


350  PROGNOSIS  IN  LYMPHATIC  INFECTIONS 

(b)  if  the  mononuclear  cells  do  not  increase  at  all  or 
decrease  immediately  after  infection;  (c)  if  the  poly- 
nuclear  cells  decrease  constantly. 

He  made  one  blood  count  before,  one  six  to  eight 
hours,  and  one  twenty  to  twenty-four  hours  after  the 
operation  respectively  after  infection. 

After  twenty-four  hours,  the  number  of  polynuclear 
cells  only  is  of  importance;  if  they  are  below  normal  and 
keep  on  decreasing  the  prognosis  is  bad,  and  vice  versa. 

By  injecting  a  person  with  dead  streptococci, 
Zangmeister  was  able  to  test  the  resisting  power  of 
the  person  against  streptococcus  infection — "Resisteur 
probe."  If  the  resisting  power  is  reduced,  the  mono- 
nuclear cells  after  the  injection  will  show  no  increase 
or  the  increase  comes  late;  the  polynuclear  cells  will 
show  no  increase  soon  after  the  infection,  or  a  decrease. 

What  may  be  said  regarding  the  probability  of  local 
complications?  It  is  impossible  to  arrive  at  any  just 
estimation  as  to  the  probability  of  the  development 
of  tenosynovitis  and  fascial  space  abscesses.  In  my 
experience  those  patients  showing  a  brusque  onset 
with  great  pain  are  more  likely  to  have  such  complica- 
tions. The  tenosynovitis  is  more  likely  to  develop 
from  infection  implanted  on  the  volar  surface  of  the 
distal  or  middle  phalanx.  Local  accumulations  on  the 
dorsum  of  the  web  between  the  fingers  is  apt  to  develop 
from  the  callus  cracks  at  the  distal  portion  of  the  palm. 
Dorsal  subcutaneous  thenar  abscesses  appear  in  infec- 
tions of  the  thenar  palmar  surface.  Subcutaneous 
abscesses  above  the  anterior  annular  ligament  often 
occur  in  connection  with  tenosynovitis.  Ill-advised 
incision  may  determine  the  localization  of  infection  in 
various  spaces.  In  several  patients  whom  I  have  seen 
in  consultation,  I  feel  sure  that  the  tenosynovitis  which 
developed  was  directly  due  to  the  primary  incision. 


CHAPTER    XXI  I  I 

THE    TREATMENT    OF    LYMPHATIC    INFEC- 
TIONS—GENERAL DISCUSSION 

The  treatment  of  lymphatic  infections  is  based 
upon  two  principles — conservatism  and  conservation. 
In  no  type  can  more  harm  be  done  b}'  ill-advised 
incisions  than  in  this.  The  position  of  masterful 
inactivity  is  most  difficult  to  maintain,  and  yet  the 
surgeon  is  constantly  aware  that  his  tendency  to  incise 
is  due  to  his  desire  "to  do  something"  rather  than  an 
exact  knowledge  as  to  what  to  do.  We  therefore  use 
local  measures  designed  to  wall  off  and  overcome  the 
infection,  combined  with  procedures  designed  to  sup- 
port the  system  and  increase  its  resisting  powers. 
In  the  ordinary  case,  until  some  localization  is  present, 
we  apply  hot,  moist  dressings,  insist  upon  local  and 
systemic  rest,  combined  with  cathartics  and  sedatives, 
as  the  case  may  demand. 

DISCUSSION  OF  VARIOUS  PROCEDURES 

Local. — Hot,  Moist  Dressings. — Man>-  forms  of  such 
applications  arc  in  use  and  ha^'c  a  \-ogue  for  a  time. 
It  is  my  personal  opinion  that  such  applications  owe 
their  value  more  to  the  moist  heat  than  to  the  drug 
with  which  they  are  combined.  It  is  my  custom  to  use 
boric  acid  in  saturated  solution.  I  am  aware  that 
many  studies  have  been  made  from  which  conclusions 
were  drawn  as  to  its  antiseptic  property  when  absorbed 
!)>•  the  blood  stream.  It  is  probable  that  it  would  be 
unjust  to  say  that  such  minute  quantities  as  ha\"e  been 


352      THE  TREATMENT  OF  LYMPHATIC  INFECTIONS 

demonstrated  in  the  blood,  and  consequently  in  the 
urine,  can  have  no  effect,  since  no  one  knows  the  effect 
of  combining  small  proportions  of  any  chemical  solu- 
tion with  blood  serum  in  vivo,  although  in  the  test- 
tube  such  combinations  may  be  shown  to  be  without 
value.  It  would  seem  more  reasonable  to  ascribe  the 
beneficial  value  of  such  applications  to  the  dilatation 
of  the  capillaries  and  the  bringing  of  more  blood  to  the 
part,  favoring  the  walling  off  of  the  infection. 

Peculiar  value  has  been  ascribed  by  various  surgeons 
to  bichloride  solution,  creolin,  almost  all  of  the  various 
antiseptics,  ichthyol,  alcohol,  etc.  Unless  they  are 
used  for  a  particular  purpose,  however,  it  would  seem 
that  hot  boric  solution  will  be  as  efficient  as  any. 

Certain  special  purposes  may  be  secured  by  special 
solutions.  In  those  cases  in  which  there  is  a  foul  odor, 
a  I  to  2000  or  i  to  4000  potassium  permanganate  solu- 
tion will  be  found  of  value.  We  may  secure  some  slight 
local  antiseptic  property  in  the  use  of  alcohol  dressings, 
using  a  30  to  50  per  cent,  solution.  This  should  not  be 
kept  up  any  length  of  time.  It  is  certainly  not  neces- 
sary to  warn  the  profession  against  the  use  of  carbolic 
acid  solution  in  any  strength.  The  frequency  with 
which  carbolic  acid  gangrene  is  seen,  however,  leads 
me  to  urge  upon  physicians  the  necessity  of  informing 
patients  of  the  danger  of  this  remedy,  which  is  so  often 
the  home  application  for  all  cuts  and  injuries. 

The  method  of  applying  hot  boric  dressings  has  been 
discussed  on  p.  72.  They  are  so  applied  as  to  cover 
the  entire  forearm  and  arm  in  the  severe  cases.  It  is 
a  good  rule  to  make  the  dressing  much  larger  than  the 
condition  would  seem  to  call  for.  These  hot,  moist 
dressings  are  to  be  used  until  the  red  line  of  lymphatic 
involvement  has  entirely  disappeared  and  any  acute 
edema  has  begun  to  subside,  at  which  time  a  change 
should  be  made  to  a  dry  dressing  of  some  kind. 


DISCUSSION  OF  r./R/Ol  S  PROCEDURES  \\').\ 

Rest. — Both  local  and  s\sU'inic  rest  should  be  in- 
sisted ui)on,  c'spcriall)'  in  severe  infections.  The  local 
rest  is  of  especial  value  in  a  prophylactic  sense,  since 
every  movement  of  the  finc^ers  or  hand  tends  to  favor 
lymphatic  circulation  and  hence  to  favor  dissemina- 
tion of  the  infection.  Von  Volkmann  and  others 
liaxe  advised  suspending  the  arm  so  that  the  hand  is 
elevated.  It  does  not  seem  that  this  would  be  of  value 
except  to  relieve  the  pain  of  a  congestion,  and  it  has 
not  seemed  to  me  to  influence  the  course  favorably. 

The  Bier  Treatment. — The  place  of  the  Bier  treat- 
ment in  infections  of  the  hand  has  already  been  touched 
upon  (\).  71).  In  these  lymphatic  infections  I  have 
used  it  only  in  the  same  sense  that  we  would  use  a 
ligature  to  prevent  the  rapid  absorption  of  any  poison, 
as,  for  instance,  in  the  slow  absorption  permitted  in 
snake  bites.  It,  therefore,  would  find  a  place  in  the 
early  hours  of  a  virulent  lymphatic  infection  in  which 
the  system  may  be  receiving  large  doses  of  virulent 
toxins  without  seeming  to  have  the  reactive  power 
necessary  to  wall  ofif  the  infection.  Here  the  constrictor 
is  applied  for  from  twelve  to  eighteen  hours,  tight 
enough  to  secure  a  marked  edema.  This  is  done  with 
the  hope  that  the  lack  of  reaction  upon  the  part  of  the 
system  is  due  in  part  to  the  fact  that  it  is  overwhelmed, 
and  that  if  small  doses  are  allowed  to  enter  the  system 
a  marked  antitoxin  will  be  developed  which  will  be 
able  to  withstand  the  toxin  if  its  entrance  into  the 
system  is  spread  over  some  time.  Whether  or  not 
diapedesis  of  leukocytes  in  these  infections  is  favored 
by  passive  congestion  is  a  moot  question. 

The  method  of  applying  the  bandage  is  as  follows: 
A  Martin  bandage  two  inches  wide  is  used.  The  band- 
age is  begun  at  a  point  slightly  above  the  elbow  and  car- 
ried to  a  point  slighth'  below  the  axilla.     Several  turns 

are  carried  about  the  arm.  so  made  as  to  j")reserve  an 
23 


354      THE  TREATMENT  OF  LYMPHATIC  INFECTIONS 

equable  pressure  throughout.  The  pressure  should  be 
sufficient  to  produce  a  moderate  edema  in  an  hour,  and 
should  not  be  sufficient  to  produce  pain.  The  method 
used  by  some  of  wrapping,  a  towel  about  the  arm  and 
securing  constriction  by  a  rubber  tube  or  narrow 
rubber  band  is  unwise,  since  it  will  cause  considerable 
pain  and  is  more  likely  to  produce  nerve  injury.  After 
the  bandage  has  been  in  place  twelve  to  eighteen  hours 
it  is  removed  and  replaced  in  a  couple  of  hours  if  the 
toxemia  is  still  high.  Ordinarily,  one  or  two  eighteen- 
hour  periods  is  all  I  have  found  of  advantage  in  these 
cases. 

Incisions. — There  may  be  some  difference  in  opinion 
as  to  the  advisability  of  these  under  certain  conditions. 

There  are  those  who  teach  that  an  incision  made  at 
the  point  of  great  pain  and  tenderness  when  it  is  the 
site  of  the  primary  infection  will  be  of  value.  They 
maintain  that  such  an  incision  if  it  does  not  evacuate 
pus  favors  drainage  about  the  site  of  the  infection,  and 
that  the  escaping  serum  carries  off  the  bacteria.  It  is 
my  own  belief  that  this  hope  is  seldom  justified,  and 
that  the  incision  simply  opens  new  lymphatics  for 
infection  and  fails  to  reach  the  bacteria  which  have 
already  entered  the  lymphatic  stream  and  are  multi- 
plying some  distance  from  the  site  of  entrance.  There- 
fore, the  prophylactic  incision  fails  of  its  purpose  and 
may  do  much  harm  by  producing  complications. 

Shall  incisions  be  made  along  the  line  of  lymphatics? 
In  those  cases  in  which  there  is  one  or  possibly  two  red 
lines  of  lymphatic  involvement  running  up  the  arm  the 
advice  to  make  a  transverse  incision  through  the  skin 
and  subcutaneous  tissue,  so  as  to  prevent  the  channel 
from  carrying  more  toxin,  seems  logical,  and  I  have 
carried  it  out  in  a  few  cases.  I  am  convinced,  however, 
that  the  procedure  is  likely  to  do  more  harm  than  good, 
since  it  pours  out  into  the  wound  the  virulent  bacteria 


P/SCi'SSION  Of  r.lR/Ol  S  PROCEDURES  :inr> 

and  toxins  which  at  the  end  of  a  few  hours  begin  t(; 
be  absorbed  in  greater  amount  than  before.  The 
picture  presented  by  this  procedure  is  very  character- 
istic. Within  an  hour  after  the  cut  is  made  the  part 
proximal  to  the  incision  becomes  pale,  the  red  lymi:)hatic 
disappears,  and  the  surgeon  feels  that  his  procedure  has 
been  justified  by  the  results.  At  the  end  of  a  few  hours, 
however,  it  is  seen  that  the  portion  distal  to  the  incision 
has  begun  to  assume  a  reddish  tinge,  and  shortly  a 
considerable  area  takes  on  the  characteristic  appear- 
ance of  an  erysipelas,  with  an  aggravation  of  the 
symptoms. 

In  other  instances  the  little  lacunae  found  in  the  course 
of  the  lymphatic  vessels  (see  p.  319)  show  small  areas 
the  size  of  a  bean  in  the  course  of  the  lymphatics,  at 
which  sites  there  is  a  local  swelling  and  edema.  These 
are  most  common  on  the  dorsum  of  the  hand.  The 
thoughtless  are  inclined  to  incise  these  under  the  im- 
pression that  localization  will  be  found  there  and  that 
drainage  is  indicated.  If  incision  is  made,  however, 
only  a  small  amount  of  serum  will  exude,  and  in  the 
severe  cases  the  procedure  is  generally  followed  b}-  a 
chill  and  rise  of  fever  within  an  hour  or  two,  sometimes 
to  an  alarming  degree,  w^hile  the  procedure  is  detri- 
mental rather  than  beneficial  to  the  ultimate  c(Kirse. 

If  incision  is  made  in  these  cases  for  any  cause,  the 
possibility  of  spreading  the  infection  must  be  borne  in 
mind  and  one  should  seek  at  least  to  prevent  rapid 
absorption.  This  is  done  by  keeping  the  arm  absolutely 
at  rest  and  applying  a  Bier  constrictor  to  the  arm. 
This  should  be  left  on  for  from  twelve  to  eighteen 
hours.  These  incisions  will  be  called  for  in  those  cases 
in  which  localization  in  the  tendon  sheaths  or  in  the 
subcutaneous  tissues  has  taken  place,  as,  for  instance, 
on  the  back  of  the  forearm  or  about  the  glands.  (For 
a  discussion  of  these,  see  p.  359.) 


356      THE  TREATMENT  OF  LYMPHATIC  INFECTIONS 

Systemic  Treatment. — Antagonistic  Drugs. — Vari- 
ous drugs  have  been  vaunted  from  time  to  time  as  of 
exceptional  value  in  septic  conditions.  They  may  be 
classified  as  those  designed  to  destroy  bacteria  and 
those  to  neutralize  the  toxin.  The  value  of  any  of 
them  is  questionable.  Quinine  has  been  used  for  many 
years,  and  if  it  were  of  marked  value  sufficient  positive 
evidence  should  have  accumulated  by  this  time  to 
leave  no  doubt,  and  this  cannot  be  said  to  be  true. 
The  same  may  be  said  of  urotropin  and  the  various 
silver  salts  which  have  been  vaunted  so  highly.  Upon 
none  of  these  can  the  surgeon  depend  with  any  distinct 
hope  that  they  will  be  of  value.  The  use  of  whisky  is 
in  a  different  class.  Any  value  it  may  have  depends 
upon  the  fact  that  its  elements  are  less  stable  than 
normal  cell  protoplasm,  and  consequently  there  is 
some  hope  that  the  toxin  may  unite  with  these  rather 
than  cause  destruction  of  the  living  cells.  There  may 
be  some  truth  in  this.  The  trouble  is  that  to  be  of 
much  value  in  this  regard  there  should  be  a  consid- 
erable amount  in  the  blood,  and  the  excretion  of 
any  considerable  amount  would  be  injurious  to  the 
kidneys. 

In  this  connection  it  has  been  my  habit  to  give  these 
patients  who  are  seriously  ill  fully  peptonized  food 
per  rectum  if  they  cannot  take  it  by  mouth,  so  as  to 
introduce  into  the  blood  peptones,  less  stable  than 
normal  albumin  of  the  living  cells,  with  the  hope  that 
the  toxins  will  unite  with  the  less  stable  combinations 
and  thus  protect  the  system.  This  can  do  no  harm, 
and  may  do  good. 

Related  to  this  we  have  the  use  of  normal  salt 
solution  introduced  into  the  system  per  rectum,  as 
well  as  large  amounts  of  water  and  fluids  by  mouth. 
In  serious  cases  the  normal  salt  may  be  given  subcu- 
taneously.     It  is  my  belief  that  the  introduction  of 


DISCISSION  or  J'ARIOIS  PROCEDURES  357 

lar.uc  anioiinls  of   (liiid    with    the   idea   of  (liluliii;^   and 
cliniinadn.u   the  loxiiis  is  of  i;rcal   \aliic. 

Scriuii  and  Vaccine  Trcatnicnt. — Wc  have  not  as  yvi 
developed  any  scrum  or  vaccine  that  can  be  said  to 
be  of  definite  value  in  these  acute  cases.  The  field  is 
a  most  engaging  one,  and  many  attempts  have  been 
made  to  produce  an  antitoxin.  The  difficulties  seem 
to  be  almost  insuperable.  If  given  very  early  it  might 
have  some  effect,  since  some  of  the  sera,  such  as  that  of 
Aronsen,  have  some  bactericidal  in  addition  to  its  anti- 
toxic and  opsonizing  efifect.  Often  the  toxemia  is  well 
advanced,  and  such  an  immense  amount  of  antitoxin 
would  be  necessary  to  "neutralize  the  toxins  that  we 
cannot  hope  to  inject  it,  and  the  opsonizing  and  bac- 
tericidal effects  are  insufficient.  Moreover,  it  has  been 
shown  many  times  that  the  antitoxin  prepared  for 
one  type  of  streptococcus  will  have  no  elTcct  upon  the 
toxins  generated   by   a  second   type   of  streptococci.^ 

Van  de  Velde  showed  that  the  leukocidin  produced 
by  one  staphylococcus  pyogenes  aureus  might  be  al- 
most innocuous,  while  another  might  be  most  virulent. 
Denys,  Van  de  Velde,  Neisser,  and  Wechsberg  have 
produced  antileukocidin,  but  it  must  be  for  the  specific 
organism. 

Therefore,  to  secure  the  best  results  a  serum  must 
be  made  from  the  germ  producing  the  disease,  and  this 
is  manifestly  impossible,  since  the  time  is  too  short. 
In  attempts  to  obviate  this  difficulty  some  have  made 
their  antistreptococcus  serum  from  a  combination  of 
several  strains  of  streptococci,  i.  e.,  the  so-called  pohv- 
alent  antistreptococcus  sera,  such  as  those  of  Tavcl, 
Moser,  Alenzer  and  others,  while  the  sera  of  Alarmorek 
and  others  is  monovalent,  i.  e.,  made  from  one  strain. 
Whether  these  sera  act  in  a  bactericidal  or  antitoxic 

*  Meakins,  Phagocytic  Immunity  in  Streptococcus  Infection,  Jour,  of  Exper. 
Med.,  xi,  815. 


358      THE  TREATMENT  OF  LYMPHATIC  INFECTIONS 

manner  or  by  stimulating  cellular  activity  is  a  subject 
for  discussion,  but  at  least  the  effect  is  inadequate.  It 
is  possible  that  in  the  more  chronic  types  vaccines  may 
be  produced  that  will  aid  somewhat.  In  this  connec- 
tion a  perusal  of  Case  XXIV  should  be  of  interest. 
In  this  case  almost  all  of  these  methods  were  tried 
without  avail. 

The  injection  and  use  of  elements  designed  to  increase 
leukocytosis  is  another  favorite  method  of  treatment. 
For  this  purpose  several  drugs  have  been  used,  as,  for 
instance,  protonuclein  and  nucleic  acid,  but  without 
definite  results.  His  has  recently  suggested  the  injec- 
tion of  sterile  exudate,  secured  incident  to  aseptic 
injections  of  the  pleural  cavities  of  lower  animals  with 
aleuronat.     As  yet  this  has  not  secured  a  trial. 

In  spite  of  the  lack  of  definite  results  by  any  of  these 
methods,  one  cannot  but  hope  that  the  future  holds 
some  promise  of  aid  from  these  studies.  The  surgeon 
should  always  have  in  mind  the  possibility  of  value 
from  the  sera,  watching  his  cases  closely  for  a  favorable 
opportunity;  but  as  the  case  now  stands  it  is  my  per- 
sonal opinion  that  he  is  not  in  position  to  promise 
his  patients  any  distinct  curative  action  in  the  more 
acute  cases. 

Supportive  Measures. — Supportive  measures  in  the 
way  of  stimulants,  fresh  air,  good  food,  attention  to 
the  bowels,  and  proper  rest  should  not  be  neglected. 
The  fresh  air  and  sunlight,  especially  in  the  more 
chronic  cases,  is  of  distinct  value.  One  patient  suffer- 
ing from  such  a  chronic  infection,  which  defied  all 
manner  of  treatment,  was  transferred  to  an  open  air 
sun  room  where  he  lived  and  slept.  The  benefit  of 
the  change  was  evident  to  everyone  (see  Case  XXIV). 


CHAPTER    XXIV 

THE  TREATMENT  OF  THE  COMPLICATIONS 
OF  LYMPHANGITIS 

TENOSYNOVITIS 

Attention  has  been  drawn  to  the  frequency  of 
tenosynovitis  in  lymphatic  infections  beginning  in  the 
distal  phalanges  on  the  volar  surface.  In  the  chapter 
dealing  with  the  subject  of  tendon-sheath  infections 
(Chapter  XI),  a  complete  discussion  has  been  given 
which  should  enable  the  student  to  diagnosticate  the 
presence  of  such  a  complication,  and  rules  have  been 
laid  down  for  the  treatment  that  has  been  most  suc- 
cessful in  my  hands.  There  only  remains,  therefore, 
a  discussion  of  such  general  principles  as  pertain  to 
lymphangitis  in  particular. 

If  the  patient  complains  of  great  pain  over  the  tendon 
sheath  when  the  primary  puncture  has  been  upon  the 
volar  surface  of  the  finger,  even  though  the  pain  has 
not  extended  to  the  entire  finger,  one  should  be  es- 
pecially on  his  guard,  and  the  moment  that  the  tender- 
ness has  extended  from  the  site  of  the  infection  to 
involve  the  distribution  of  the  subjacent  tendon  sheath, 
the  incision  should  be  made  exposing  the  sheath.  It 
one  delays  longer,  destruction  of  the  synovial  covering 
will  have  occurred,  in  which  case  the  prognosis  for 
function  is  much  more  grave.  It  is  my  habit  to  make 
lateral  incision  on  one  or  both  sides  of  the  middle  and 
proximal  jihalanges,  and  thus  secure  drainage,  being 
careful  not  to  produce  a  secondary  infection,  and  also 
using  care  to  cut  far  enough  toward  the  \-olar  surface 


360     TREATMENT  OF  COMPLICATIONS  OF  LYMPHANGITIS 

to  avoid  the  lateral  vessels  and  nerve  which  run  up 
the  sides  of  each  finger.  If  there  is  much  destruction 
of  the  synovial  covering  parietal  and  tendinous,  it 
will  be  advisable  to  lengthen  the  incision  upon  one  side 
so  as  to  connect  the  two  phalangeal  cuts,  thus  giving 
free  drainage  but  preventing  a  prolapse  of  the  tendon 
because  of  the  lateral  site  of  the  incision.  This  is 
further  prevented  by  placing  a  dorsal  splint  upon  the 
finger  and  hand,  which  tends  to  keep  the  finger  in 
extension  and  thus  favor  retention  of  the  tendon  in 
its  proper  place.  If  one  is  very  prompt  in  the  incision, 
so  that  no  destruction  has  taken  place,  he  is  gratified 
and  surprised  at  the  rapid  recovery  he  secures.  Some- 
times it  is  entirely  well  by  the  end  of  ten  days  or  two 
weeks.  If  the  process  has  lasted  some  time,  it  is 
frequently  necessary  to  incise  at  the  side  of  the  finger 
over  the  lumbrical  space  to  secure  drainage  of  the 
loose  tissue  here  and  in  the  web.  Care  should  be  taken 
here  not  to  cut  the  blood  supply.  If  there  is  doubt  as 
to  the  side  involved,  it  may  be  best  to  cut  down  upon 
the  median  surface  over  the  proximal  end  of  the  sheath 
in  the  palm  and  then  secure  drainage  from  either  side 
through  this  incision  by  inserting  an  artery  forceps 
into  the  loose  tissue  at  the  side  and  separating  the 
blades  so  as  to  give  free  exit  to  the  pus  (see  p.  252,  and 
Figs.  87  and  89).  If  vaseline  gauze  drainage  is  inserted 
in  the  early  cases,  it  can  be  removed  the  next  day. 
If  the  thumb  or  little  finger  is  the  source  of  the  in- 
fection, the  radial  or  ulnar  bursse  are  opened  after  the 
method  described  in  Chapter  XVI.  If  there  is  no 
tenderness  above  the  wrist  it  may  not  be  necessary  to 
make  the  lateral  incision  above  the  flexor  surface  of 
the  ulna  and  radius.  If  there  is  any  tenderness,  how- 
ever, or  swelling,  incisions  should  be  made  at  once  and 
drainage  instituted  (see  p.  258).  Before  any  incisions 
are  made  the  Martin  elastic  bandage  should  be  applied 


SUBCUT.'INKOVH  .fBSCESSES  'MM 

{()  ihc  arm,  and  lollt  )\\  iiijj,  llic  opci'at  ion  il  should  he 
loosened  oiil\  lo  (lie  (leL;ree  iiecessai'V'  lo  i)rodiiee  a 
marked  Bier's  hyperemia.  This  helps  U)  wash  the 
toxins  out  of  the  tissue  adjacent  to  the  wound,  and  also 
prevents  the  rapid  absorption  of  toxins,  a  fact  which 
I  have  already-  discussed.  All  the  various  kjcations 
of  pus  secondary  to  tendon-sheath  infections  and  the 
proper  procedures  indicated  in  their  treatment  have 
been  discussed  in  Chapter  XVI. 

SUBCUTANEOUS  ABSCESSES 

Subcutaneous  abscesses  frequently  appear  upon  the 
dorsum.  As  soon  as  a  definite  redness  and  hardness 
have  appeared,  indicating  pus,  free  incisions  should  be 
made.  Simple  redness  and  edema  is  not  sufficient  to 
indicate  incision,  but  when  the  hardness  has  been  added 
free  incisions  under  the  same  precautions  as  mentioned 
above  should  be  made.  The  presence  of  extensive 
subcutaneous  destruction  of  the  connective  tissue  with 
the  formation  of  a  slough  with  streptococcic  pus  is 
one  of  the  most  serious  complications.  Incision  should 
be  made  early,  in  several  places  upon  the  dorsum,  so 
as  to  give  perfect  drainage.  At  the  risk  of  useless 
repetition,  let  me  say  again  that  I  am  speaking  of 
the  indurated,  brawn^^  dark  red  dorsum,  characteristic 
of  the  spreading  virulent  phlegmon,  not  of  the  pinkish, 
edematous,  pitting  dorsum.  Neither  am  I  speaking 
of  the  simple  staphylococcic  abscess.  The  gravity  of 
this  severe  type  has  long  been  recognized.^ 

^  Bauchet  thus  describes  how  they  were  considered  and  treated  by  Velpeau : 

"An  unconfmed  phlegmon  is  one  of  the  most  serious  complications  of  a 
whitlow.  It  is  heralded  by  a  series  of  serious  symptoms  here  as  in  all  other 
parts,  by  a  considerable  swelling,  and  a  characteristic  dull,  j^ellowish  redness. 

"The  diffuse  phlegmon  is  undoubtedly  a  serious  matter  when  it  appears 
on  the  back  of  the  hand,  but  it  is  even  more  dangerous  when  it  invades  the 
forearm  and  arm. 

"The  first  symptoms  of  this  awful  complication  once  recognized,  one  must 
not  hesitate  to  have  recourse  to  the  most  drastic  therapeutic  measures;  anti- 


362     TREATMENT  OF  COMPLICATIONS  OF  LYMPHANGITIS 


PERIGLANDULAR  ABSCESSES 

Periglandular  abscesses  occur  especially  on  the  epi- 
trochlear  and  axillary  regions.  These  are  not  so 
virulent  as  the  type  just  described,  and  a  more  conser- 
vative course  may  be  pursued.  Since  they  start  from 
glandular  suppuration,  some  days  will  elapse  before  they 
become  evident.  The  surgeon  will  often  be  in  doubt 
for  a  day  or  two  as  to  whether  the  infection  may  not 
be  a  simple  glandular  hyperplasia.  The  waiting  period 
is  not  without  advantage  to  the  patient,  since  it  offers 
an  opportunity  for  the  abscess  to  become  walled  off, 
and  thus  favors  the  prevention  of  extension  when  it 
is  opened. 

SUBCLAVICULAR  AND  SHOULDER  ABSCESSES 

The  occurrence  of  such  an  abscess  will  of  course  be 
rare,  since  they  arise  in  the  course  of  the  lymphangitis 
extending  along  the  lymphatics  lying  in  the  pectero- 
deltoid  groove,  having  its  origin  most  commonly  in 
the  middle  finger.  It  has  been  my  fortune  to  meet  with 
only  one  such  case,  and  this  began  in  the  index  finger. 
Dr.  J.  M.  Neff,  of  Spokane,  has  seen  and  operated  upon 
another  one,  in  which  the  origin  was  in  the  middle 
finger,  followed  in  three  days  by  a  subclavicular  ab- 

phlogistics,  local  and  general  baths,  purgatives,  opiates,  and  the  arm  placed 
in  an  elevated  position.  If  at  the  end  of  twenty-four  or  thirty-six  hours  the 
symptoms  do  not  mend,  and  if  the  disease  seems  stationary,  one  must  insist 
upon  the  compresses,  if  the  patient  has  been  able  to  stand  them,  after  generous 
applications  of  ointments  of  mercury.  If  the  compresses  increase  the  pain, 
one  may  profitably  resort  to  the  application  of  a  large  volatile  vesicatory, 
covering  all  the  diseased  parts.  This  means,  so  extolled  by  M.  Velpeau,  has 
and  always  will  render  good  service. 

"However,  if  the  general  symptoms  continue  to  grow  worse,  if  the  swelling 
increases,  the  moment  to  proceed  with  the  bistoury  has  come,  and  three  or 
four  long  deep  incisions  must  be  made.  This  is  the  only  road  to  recovery  left 
to  the  patient." 


cuRosn:  /x/r.cr/oxs,  Ri:pi:,iri:i)  fxri-crioxs    :\(\:i 

scc'ss.  which  was  opened,  <iii<l  I  his  m  inni  was  lollowcd 
l)\'.  or  acronipanied,  a  s\no\ilis  ol  a  knee-jcji'iil  of  a 
serious  nature,  hul  from  which  the  patient  ultiniateh' 
recovered.  This  case  then  is  most  interesting,  since  it 
emphasizes  the  origin  of  these  abscesses  and  also  serves 
to  emphasize  what  I  have  previoush'  called  attention 
to,  and  that  is  the  seriousness  and  frequency  of  sys- 
temic involvement  from  lymphangitis  originating  in 
the  middle  finger. 


SYSTEMIC  COMPLICATIONS 

These  must  be  met  as  they  arise  and  the  treatment 
based  upon  the  general  surgical  principles  governing 
septicemia  and  pyemia.  The  metastatic  abscesses 
should  be  opened,  empyemas  drained,  pneumonia,  etc., 
guarded  against  with  every  possible  precaution. 

The  question  of  amputation  of  the  arm  in  these 
severe  cases  will  be  a  constant  one,  but  no  definite 
rules  can  be  laid  down.  One  will  constantly  feel  in  the 
early  cases  that  amputation  is  too  severe  for  the  con- 
dition, and  when  systemic  infection  has  begun  it  will 
be  considered  that  amputation  will  be  futile,  so  that 
the  indications  for  amputation  will  be  drawn  between 
narrow^  lines.  In  exceptional  cases  some  hope  ma\'  be 
offered  by  this  procedure,  as,  for  instance,  in  a  spreading 
I)hlegmon  or  in  a  malignant  edema. 

CHRONIC  INFECTIONS;  REPEATED   INFECTIONS 

It  is  an  unfortunate  fact  that  one  infection  with  a 
streptococcus  does  not  immunize  the  patient;  at  least, 
if  it  does,  it  is  onh'  for  a  short  time.  Not  only  are 
repeated  infections  possible,  but  one  infection  seems 
almost  to  favor  a  second  a^  a  later  date.  This  is  not 
true  to  the  same  degree  with   the  stai)h\lococcus,  by 


364     TREATMENT  OF  COMPLICATIONS  OF  LYMPHANGITIS 

which  a  mild  degree  of  immunization  may  be  vSecured. 
This  is  demonstrated  by  the  raising  of  the  opsonic 
index  as  determined  by  the  Wright  method.  The 
streptococcus  particularly  not  only  may  not  develop 
immunization,  but  also  lacks  to  a  marked  degree  the 
power  in  many  cases  to  produce  antitoxins  in  a  degree 
sufftcient  to  overcome  itself,  so  that  we  often  see  cases 
of  chronic  long-continued  infection  which  undoubtedly 
had  their  origin  in  a  streptococcus  infection.  No  better 
example  of  this  type  of  infection  could  be  cited  than 
that  of  a  case  I  saw  with  Dr.  Oleson,  of  Lombard,  111. 
It  is  true  that  another  factor  came  into  this  case, 
namely,  that  the  infection  had  possibly  come  from 
organisms  which  had  passed  through  a  lower  animal, 
which  we  know  may  change  the  virulence  in  many  ways. 
The  case,  however,  is  worth  a  careful  perusal,  since 
it  was  so  carefully  and  conscientiously  treated  by 
Dr.  Oleson  by  every  known  scientific  method,  and  yet 
it  resisted  treatment  for  over  two  years,  the  patient 
apparently  not  having  the  slightest  ability  to  develop 
antitoxins.     He  has  now  completely  recovered. 

Dr.  Oleson  has  already  reported  the  case,  and  I 
herewith  abbreviate  his  report: 

Case  XXIV. — "On  June  15,  1906,  over  three  years 
ago,  the  patient  removed  a  wart  from  the  index  finger 
of  his  right  hand,  leaving  an  opening  in  the  subcu- 
taneous tissue  which  did  not  readily  close.  While  this 
condition  existed  he  received  orders  to  care  for  some 
sick  calves,  afflicted  with  a  disease  which  caused 
dyspnea,  with  considerable  salivation.  In  giving  them 
medicine  it  was  necessary  for  him  to  introduce  his 
right  hand  into  their  mouths,  with  the  natural  conse- 
quence that  it  became  covered  with  their  slobbery 
saliva.  In  a  few  days  he  sickened  and  called  in  Dr. 
William  Dillon,  of  Urbana,  who  reports  under  date  of 
August  18,  1906,  substantially  as  follows: 


CIIROMC  IMECTIOSS;  REPEATED  INFECTIONS      3G5 

'"In  regard  to  Mr.  J.'s  illness,  I  was  called  to  his 
room  about  9  p.m.,  June  2y  (1906).  I  found  him  King 
down,  \\ith  perspiration  in  large  drops  over  his  face, 
pulse  full  and  rapid,  temperature  about  103°  F.  Pain 
about  axilla.  Axillary  glands  indurated  and  enlarged. 
There  was  a  small  unhealed  place  in  the  centre  of 
a  spot  on  one  of  his  right  fingers,  from  which  I 
could  press  out  a  little  serum,  but  which  had  no  sore- 
ness. I  ordered  fomentations  during  the  night,  with 
magnesia  sulphate  internalh'.  The  following  morning 
there  was  less  pain,  but  more  fever,  and  I  had  him 
removed  to  a  hospital,  where  the  treatment  was  con- 
tinued. The  glands  returned  to  their  normal  size  so 
far  as  could  be  detected,  but  fever  and  sweating  con- 
tinued. About  the  third  day  in  the  hospital  painful 
tympanites  developed,  also  swelling  along  the  general 
direction  of  the  pectoralis  tendon  from  a  little  below 
the  arm-pit  to  near  the  eleventh  rib.  This  was  the  first 
appearance  of  localization.  I  called  in  Dr.  Newcomb, 
who  aseptically  incised  the  tissues  down  through  the 
deep  fascia.  A  little  serum  escaped.  About  July  22  the 
second  incision  was  made  and  the  entire  cavity  washed 
out  with  bichloride  and  dressed  with  dry  dressings. 
Now^  the  patient  rapidly  improved  and  the  abscess 
walls  united  so  that  when  irrigated  the  fluid  would 
extend  but  a  short  distance  in  any  direction.  The  pus 
^y  July  30  had  almost  ceased.  Temperature  normal, 
pulse  normal,  patient  bright,  no  sweating.'" 

Dr.  Oleson  here  continues: 

"I  first  saw  the  patient  on  August  10,  1906.  On 
entering  my  ofBce  a  limitation  of  motion  in  the  right 
shoulder  and  a  marked  cervical  scoliosis  was  evident. 
He  was  pale,  anemic;  pulse,  106;  temperature,  98°  F. 
At  the  anterior  margin  of  the  right  axilla,  along  the 
border  of  the  pectoralis  major,  aj^peared  a  long  scar, 
presenting  at  its  uj^per  end  a  small  orifice  discharging 


366     TREATMENT  OF  COMPLICATIONS  OF  LYMPHANGITIS 

a  thin  blue-green  serum.  A  second  opening  existed  to 
the  axillary  side  of  the  scar,  about  an  inch  below  the 
first  sinus.  No  swelling,  some  redness,  tenderness 
slight,  shoulder-joint  motion  limited,  evidently  from 
scar  contraction.  A  flexible  sterilized  probe  introduced 
into  the  sinus  with  strict  asepsis  passed  under  the 
clavicle  for  some  distance  toward  the  vertebrae,  so  that 
the  general  clinical  picture  simulated  a  cervical  Pott's. 
But  a  few  days'  study  satisfied  me  that  there  was  no 
vertebral  disease,  nor  could  I  find  evidence  of  any 
shoulder-joint  trouble. 

"He  passed  into  the  hands  of  a  neighboring  sectarian 
practitioner,  and  after  some  weeks  of  unimprovement 
entered  a  homeopathic  hospital  in  this  city.  Here  the 
gradually  enlarging  ulcer,  which  appeared  at  the  site 
of  the  sinus  and  slowly  spread  downward  along  the 
thoracic  wall  in  the  direction  of  the  original  incision, 
was  curetted,  and  the  patient  received  considerable 
x-ray  treatment,  with  steady  failure  of  his  vital  forces 
until  the  latter  part  of  March,  1907,  some  nine  months 
after  the  original  infection,  when,  on  the  suggestion 
of  the  hospital  authorities,  he  was  taken  from  the 
institution  to  end  his  days  among  his  friends.  Here 
I  saw  him  on  March  28,  1907,  since  which  time  he  has 
been  continuously  under  my  care.  He  presented  then 
the  typical  picture  of  advanced  chronic  sepsis.  He  was 
thin,  haggard,  with  a  marked  Hippocratic  facies, 
scoliosis  more  evident,  temperature  running  a  classical 
hectic  curve  (morning  remissions  to  98°  F.,  evening 
readings  varying  around  102°  F.),  then  constantly 
between  120°  and  130°,  having  the  appearance  of 
impending  death.  Locally  the  margins  of  the  sinus 
had  broken  down  to  form  along  the  thoracic  wall  a 
deep  ragged  ulcer  as  large  as  the  palm  of  one's  hand 
with  sinuses  radiating  upward,  forward,  and  downward, 
honeycombing  the  tissues  in  the  pectoral  region,  while 


CIIROMC   IMF.CriOSS;    RliPI- .IT  1:1)   IMECTIOXS       'Mu 

over  the  third  and  loiirlh  ri^ht  costocliondral  junc- 
tions appeared  bluisli-rcd  d(|)rc'sscd  areas,  evidently* 
niarkini^'  points  at  which  i)us  was  al)out  to  appear. 
The  former  bluish-green  dischari^e  was  now  ahiKjst 
colorless,  very  profuse,  and  of  a  thin  sennis  nature, 
soaking  large  gauze  dressings  daih'. 

"On  April  6,  1907,  under  chloroform  anesthesia  by 
Dr.  Pickard,  with  Dr.  W.  F.  Scott  assisting  me,  I 
removed  inflamed  periosteum  and  perich(jndrium,  with 
subjacent  necrotic  tissue  at  the  points  indicated  by 
the  discolored  skin,  curetting  from  all  accessible  places 
the  various  sinuses,  scraping  out  large  quantities  of 
soft,  pale,  pulpy  friable  granulations,  with  free  hem- 
orrhage easily  checked  by  pressure.  The  patient  was 
put  to  bed  in  an  exhausted  condition,  while  my  con- 
sultants cheerfully  foretold  an  early  lethal  termination. 

"On  May  6,  1907,  I  performed  a  second  similar 
operation,  attacking  new^  fresh  necrotic  areas  over  the 
second  and  fifth  costochondral  junctions.  The  result 
of  these  two  operations  w-as  a  considerable  improve- 
ment in  the  pulse  curve,  which  now  rarely  went  over 
no,  while  the  temperature  did  not  pass  above  101°, 
with  no  local  change  except  the  healing  of  one  sinus 
which  had  invaded  the  tissues  from  the  lower  margin 
of  the  ulcer. 

"On  July  6,  1907,  T  performed  what  was  intended 
for  a  radical  operation,  by  making  a  deep  curved  inci- 
sion from  the  lower  border  of  the  ulcer,  anteriorh-  to 
the  sternum,  separating  the  entire  pectoral  flap  ot 
muscles,  reflecting  them  back  over  the  shoulder  and 
exposing  this  region  for  general  curettage. 

"After  thorough  scraping  of  all  other  lesions  the 
flap  of  muscle  was  sutured  back  into  place.  The  patient 
did  not  react  well,  it  being  se\eral  days  before  he  ceased 
vomiting,  and  the  general  immediate  result  ol  this 
intervention   was   the   acttial   sjiread   of   the   inli'ction, 


368     TREATMENT  OF  COMPLICATIONS  OF  LYMPHANGITIS 

as  it  followed  each  suture  and  needle  puncture  into  new 
regions,  reaching  around  also  into  the  intermuscular 
septa  and  subcutaneous  tissue  of  the  back,  a  region 
previously  uninvaded.  Various  abscesses  were  opened 
during  the  next  month. 

"During  all  this  time  the  wound  had  been  dressed 
by  daily  irrigation  through  drainage  tubes  or  along 
the  sinus  tracts.  All  sorts  of  fluids  had  been  used — ■ 
normal  saline,  plain  sterilized  water,  iodine  water, 
hydrogen  peroxide,  pure  and  in  solutions  of  varying 
strengths,  bichloride  and  phenol  dilutions,  with  no 
appreciable  improvement.  On  September  2,  1907,  I 
made  a  radical  change,  permanently  abandoning  all 
forms  of  irrigations,  and  substituting  plain  dry  sterile 
dressings,  with  immediate  marked  improvement  in  the 
general  condition.  The  temperature  fell  to  99°  and 
remained  there,  while  the  pulse  varied  between  90  and 
100.  There  had  been  nervous  digestive  disturbances,  so 
that  any  unwelcome  suggestion,  e.  g.,  the  discussion 
of  an  anesthetic  or  the  odor  of  ether,  etc.,  would  cause 
a  prompt  and  thorough  emesis.  Yet  he  had  gained 
10  pounds  in  bodily  weight  in  five  months,  but  with 
the  cessation  of  irrigation  the  digestive  derangement 
ceased,  he  took  and  retained  large  amounts  of  food,  with 
cod-liver  oil,  sevetol,  etc.,  so  that  in  the  next  five 
months  he  gained  26  pounds,  with  corresponding  physi- 
cal improvement.  By  the  middle  of  January,  1908, 
he  was  strong,  robust,  healthy  appearing,  but  with 
absolutely  no  improvement  whatever  in  the  local 
lesion,  which  remained  stationary,  discharging  daily 
large  quantities  of  seropus,  necessitating  copious 
aseptic  dressings. 

"At  about  this  time  Dr.  Emil  Beck  announced  the 
result  of  his  work  in  the  treatment  of  certain  unhealed 
sinuses  by  the  bismuth  paste  method.  Injections  were 
given  January  22  and  28,  1908,  with  no  especial  result 


CHRONIC  INFECTIONS;  REPILITi:!)  I XFECT l(J.\S      \W.) 

excc])l  tliat  tlu'  patient's  weight  fell  olT  a  liillc  In 
order  to  give  the  j^aste  a  little  better  chance,  1  decidcfl 
to  curette  the  granulations  from  the  sinuses  again, 
and  then  to  make  a  third  injection.  This  I  did  on 
Fcbruarv'  lo,  1908,  and  on  the  morning  of  Februar\'  i  i 
1  loiind  my  patient  with  a  pulse  of  140;  temperature, 
102°;  rusty  sputum  and  consolidation  of  the  left  lower 
l(jbe.  ...  A  typical  crisis  occurred  on  the  seventh 
day,  with  uncomplicated  convalescence.  One  peculiar 
phenomenon  presented  itself  on  the  third  morning  of 
the  seizure,  when  the  patient  suddenly  expectorated  a 
single  mouthful  of  pure  pus,  of  which  the  anatomical 
origin  was  never  satisfactorily  located. 

"On  February  26,  1908,  he  returned  to  his  home, 
having  lost  17  pounds,  which  he  proceeded  to  regain. 
At  this  time,  through  the  courtesy  of  Prof.  Ormsby, 
I  secured  from  the  research  laboratory  of  Parke,  Davis 
&  Co.  a  supply  of  staphylococcus  vaccine,  varying  doses 
being  injected  on  March  14,  and  for  a  month  after- 
ward, without  effect.  Thorough  search  was  now  made 
by  Prof.  Ormsby  for  evidences  of  blastomycosis, 
actinomycosis,  and  tuberculosis,  with  negative  results. 
Prof.  Hektoen  now  generously  placed  at  m}-  disposal 
his  laboratory  facilities,  and  his  assistant,  Dr.  D.  J. 
Davis,  readily  isolated  from  the  pus  a  streptococcus 
which  grew^  abundantly  in  almost  pure  cultures,  but 
presented  no  identifying  morphological  characteristics. 
The  patient's  opsonic  index  to  this  organism  was 
subnormal. 

"On  April  16,  1908,  I  injected  the  dead  bodies  of 
500,000,000  aiitogenoiis  cocci  obliquely  into  the  subcu- 
taneous tissue  of  the  right  thigh.  In  two  days  an  indu- 
ration appeared  at  the  site  of  injection.  Twelve  days 
trom  date  of  j^juncture  fluctuation  was  e\ident  at  this 
l)oint.  On  May  6,  twent>-  days  from  the  injection, 
the  skin  here  grew  purplish.     Two  da\s  afterward,  on 

24 


370     TREATMENT  OF  COMPLICATIONS  OF  LYMPHANGITIS 

May  8,  under  aseptic  precautions,  I  aspirated  some  of 
the  contents  of  the  swelHng,  which,  on  examination 
by  Dr.  Davis,  proved  to  be  sterile,  chemical  pus.  On 
May  15,  twenty-nine  days  after  injection,  the  skin 
finally  broke  down  and  the  contents  escaped,  leaving  a 
superficial  ulcerated  area,  which  slowly  cicatrized  across 
from  the  margins,  ultimately  healing  on  July  3,  1908, 
seventy-eight  days  after  the  date  of  injection. 

"This  history  is  that  of  each  inoculation  made 
obliquely,  leaving  the  vaccine  in  the  subcutaneous 
tissue.  As  the  weeks  went  on  I  lessened  the  dose  to 
250,000,000,  60,000,000,  10,000,000,  and  each  one 
caused  the  breaking  down  of  connective  tissue,  the 
formation  of  sterile  chemical  pus,  the  death  of  the 
overlying  skin  from  starvation — -an  open  ulcer — slow 
healing,  so  that  we  finally  had  an  absolute  clinical 
demonstration  of  the  method  of  local  spread  of  this 
coccus,  namely,  by  the  secretion  of  toxins,  which  by 
their  chemical  action  on  the  connective  tissue — not  skin, 
not  muscles,  but  subcutaneous  tissue,  fasciae,  septa, 
etc. — cause  this  to  gradually  die  and  melt  away,  destroy- 
ing the  bloodvessels  which  run  in  its  meshes,  and  so 
bringing  about  the  death  of  overlying  skin  or  under- 
lying bone,  not  by  attacking  these  structures  them- 
selves, but  by  cutting  off  their  nourishment.    . 

"To  prove  this  I  then  proceeded  to  inject  the  same 
doses  of  dead  cocci  deeply  in  the  muscles  themselves, 
beginning  with  10,000,000  and  steadily  increasing 
the  quantity  until,  on  August  29,  1908,  I  gave  him 
300,000,000 — and  not  once  was  there  the  least  reaction, 
local  or  general,  to  a  single  intramuscular  injection, 
while  everyone  of  the  oblique  subcutaneous  injections 
of  the  same  cultures,  with  identical  aseptic  precautions, 
produced  local  necrosis. 

"During  this  period,  while  we  were  endeavoring  to 
do  something  to  help  the  patient  by  means  of  specific 


.  CHRONIC  IXFEC'I'IOS'S:   REPEATED  IXFECTIOSS      'M\ 

vacH-iiic,  his  L;x'iu'ral  coiulition  failed  slight!},  lie  lost 
about  S  pounds  in  weight,  and  there  was  a  slow  spread- 
ing 1)>  undermining  the  skin  around  the  affected  area, 
so  that  at  the  end  of  this  time,  when  this  method  was 
abandoned,  the  area  involved  reached  its  maximum, 
covering  the  right  side  of  the  body  from  the  sternum 
into  the  middle  of  the  right  half  of  the  back  and  extend- 
ing from  a  point  above  the  clavicle  down  beyond  the 
costal  margin— a  stretch  of  29  cm.  in  each  diameter. 
I  now  decided  to  expose  the  affected  region  thoroughly, 
and  on  September  15,  1908,  I  curetted  again  all  sinuses 
and  completely  excised  all  undermined  skin.  At  last 
this  was  followed  by  actual  healing,  beginning  in  the 
back  of  the  arm,  but  progressing  slowly. 

"For  some  time  I  had  been  anxious  to  give  my 
patient  the  benefit  of  sunshine  in  direct  application  to 
the  wound  surfaces,  but  no  practicable  method  pre- 
sented itself  to  me  on  account  of  the  large  area  to  be 
covered  and  the  very  free  divScharge.  Fortunately,  on 
November  28,  1908,  Dr.  Allen  B.  Kanavel  saw  him 
and  suggested  a  home-made  wire  cage.  This  crude 
appliance  was  applied  on  December  3,  and  proved  to 
be  the  one.  missing  link  in  the  chain  to  drag  the  patient 
back  to  health.  The  wire  cage  was  enveloped  with 
sterile  gauze,  and  so  enfolded  and  protected,  my  patient 
has  spent  the  last  ten  months  basking  in  the  sunlight, 
with  slow  but  steady  healing  of  the  local  lesions  in  all 
spots  the  sun's  direct  rays  could  reach.  The  range  of 
pulse  is  in  the  sixties,  the  temperature  normal  and  the 
general  condition  most  excellent." 

The  history  of  this  patient  serv^es  to  emphasize  that 
in  such  cases  the  general  hygienic  rules  are  of  more 
value  than  any  special  procedures.  This  would  include 
outdoor  life  and  nourishing  food,  combined  with  the 
least  possible  local  treatment  of  the  infected  areas. 
The  futilit\-  of  ^■a^^i^e  treatment  was  also  emphasized. 


SECTION    IV 
ALLIED    INEEC'JIONS 

CHAPTER    XXV 

ERYSIPELAS,    ERYSIPELOID,    GAS    BACILLUS 
INFECTION,  ANTHRAX 

ERYSIPELAS 

Erysipelas  may  appear  in  two  types:  first  an  un- 
complicated cutaneous  lymphangitis  corresponding  to 
the  picture  seen  upon  the  face,  and  second,  as  a  cutane- 
ous lymphangitis,  complicated  with  a  subcutaneous 
lymphangitis.  This  latter  type  is  more  common  in 
the  hand.  The  former,  the  rarer  type,  is  that  of  the 
typical  erysipelas  as  seen  upon  the  face  with  the 
brawny  induration  confined  to  the  skin  and  outlined 
by  a  distinct  border.  The  deep  purple-red  skin  may 
have  blebs  upon  it.  The  second  type  is  the  accompani- 
ment of  the  severe  subcutaneous  l^-mphangitis,  and  has 
been  discussed  on  pages  332  and  361. 

The  treatment  of  erysipelas  proper  is  clearh'  that 
of  a  lymphangitis  which  also  has  been  discussed  (see 
PP-  351  and  356).  No  special  applications  such  as 
carbolic  acid,  ichthyol,  salicylic  acid  can  be  considered 
to  be  of  especial  value.  In  the  superficial  t\"j:)e  the  usual 
hot,  moist  dressings  may  be  used;  the  treatment  of  the 
severer  types  referred  to,  which  are  often  called  gan- 
grenous erysipelas  or  gangrenous  cellulitis  by  surgeons, 
has  been  discussed  on  page  361. 


374  ERYSIPELAS,  ERYSIPELOID,  ANTHRAX 

ERYSIPELOID 

This  is  a  condition  seen  most  commonly  upon  the 
fingers  and  which  may  be  mistaken  for  true  erysipelas. 
The  earlier  writers  have  described  it  under  the  title  of 
chronic  erysipelas,  or  erythema  migrans.  Rosenbach 
designated  the  condition  erysipeloid,  a  name  which 
has  been  accepted  by  the  profession. 

It  commonly  has  its  origin  in  some  slight  wound, 
and  is  most  often  seen  in  those  handling  fish  and 
oysters  or  cheese  and  herring.  Therefore,  it  is  found 
among  fishermen,  butchers,  cooks,  etc.  Gilchrist  has 
described  his  findings  in  over  300  cases  which  originated 
in  crab  bites.  He  thought  the  condition  was  due  to  a 
ferment  injected  by  the  crab  bite,  and  not  to  a  special 
organism.  Rosenbach  described  a  cladothrix-like  or- 
ganism as  the  cause,  and  this  finding  was  later  confirmed 
by  Ohlemann.  It  is  an  irregular  round  organism, 
developing  into  threads  in  old  cultures.  Pathologically 
one  finds  an  invasion  of  the  corium  with  polynuclear 
leukocytes  and  a  massing  of  lymphoid  cells  about  the 
bloodvessels. 

Symptoms. — Following  a  slight  injury,  generally  upon 
the  fingers,  the  skin  becomes  swollen,  painful,  and  of  a 
deep  bluish  color.  There  is  some  local  burning  and 
itching,  but  no  fever  or  any  general  reaction.  The 
infection  extends  gradually  with  a  sharp  line  of 
demarcation  up  the  finger  into  the  hand  rarely  as  high 
as  the  middle,  but  it  may  involve  the  adjacent  fingers. 
As  it  extends,  the  older  area  becomes  pale.  A  lym- 
phangitis of  a  very  resistant  type  may  develop.  There 
are  no  papules,  vesicles,  or  suppuration.  The  disease 
lasts  from  one  to  four  weeks,  varying  with  the  treat- 
ment. 

Treatment. — Lexer  advises  immobilization  by  a  splint 
for  from  two  to  four  days,  accompanied  by  applica- 


CJS  li.lCII.IAS  fMr.CTION  :\7'> 

tions  of  \ascliiic.  II  iiiox  I'liicii  I  hcuiiis  too  carU',  llu- 
ti-oul)lc  will  iTapix'ai'.  Others  in-cominciKl  25  \n-v  ((•ill. 
salic\li("  acid  oiiitnu'iit  followed  1)\   a  hiaiid  oil. 


GAS  BACILLUS   INFECTION 

Under  this  title  many  conditions  are  included  which 
have  in  past  years  been  described  by  many  titles,  such 
as  gaseous  phlegmon,  emphysematous  gangrene,  ma- 
lignant edema,  etc.  It  is  probable  that  there  are  at 
least  two  distinct  types  here  included,  if  not  more; 
namely,  infection  by  the  bacillus  of  malignant  edema 
and  that  by  the  Bacillus  aerogenes  capsulatus.  Other 
bacteria  may  produce  gas,  and  thus  come  under  this 
classification. 

While  we  may  thus  separate  them  etiologically, 
clinically  we  must  consider  them  as  one,  since  we  cannot 
be  certain  when  making  smears  at  the  operation  with 
which  type  we  are  dealing.  We  are  wont  to  say  that 
the  more  serious  type  is  probably  due  to  the  bacillus 
of  malignant  edema,  and  the  milder  type  to  the  Bacillus 
aerogenes  capsulatus.  We  cannot  be  certain  of  this, 
however,  and  for  the  purpose  of  treatment  must 
divide  them  into  fulminating  and  subacute,  and  base 
our  treatment  upon  this  without  regard  to  the  organism 
present. 

The  condition  is  characterized  pathologically  b\'  a 
rapidly  spreading  inflammation  associated  with  the 
formation  of  gas,  the  presence  of  which  is  denoted  b\' 
the  crepitation  found  on  palpation  characteristic  of 
emphysema  elsewhere.  In  the  milder  cases,  locally, 
one  finds  a  moderate  degree  of  serum  between  the 
muscular  bodies  and  in  the  subcutaneous  tissue  asso- 
ciated with  gas.  Systemically,  one  finds  the  changes 
of  a  moderate  toxemia.  In  the  severe  cases  we  find  a 
diffuse,  watery,  semibloody  edema  of  marked   degree, 


370  ERYSIPELAS,  ERYSIPELOID,  ANTHRAX 

going  on  even  to  necrosis  of  tissue  with  gas  bubbles 
throughout.  There  is  an  absence  of  phagocytosis.  Gas 
bubbles  may  be  found  disseminated  in  the  blood 
stream.  An  excessive  amount  of  gas  speaks  for  an 
infection  by  the  Bacillus  aerogenes  capsulatus  rather 
than  one  by  the  bacillus  of  malignant  edema.  The 
finding  of  a  mixed  infection  with  streptococci  and 
staphylococci  is  not  uncommon. 

The  infection  may  begin  with  the  slightest  wound, 
but  more  often  it  is  found  with  severe  injuries  in  which 
dirt  has  been  ground  into  the  tissues.  It  has  been  my 
fortune  to  see  three  cases  in  the  arm,  two  of  which 
began  from  very  insignificant  injuries,  and  the  third 
followed  a  compound  fracture  of  a  finger. 

The  accompanying  table,  which  may  be  found  of  aid 
in  differentiating  the  various  organisms  obtained  by 
smear  or  culture  in  these  cases,  was  prepared  for  me 
by  Dr.  W.  H.  Buhlig.  It  is  designed  to  difi"erentiate 
not  alone  the  virulent  organisms,  but  also  to  separate 
these  from  the  non-pathogenic  organisms  with  which 
they  may  be  confused. 

In  the  milder  cases  the  systemic  evidences  of  toxemia 
are  not  marked.  The  local  swelling  is  frequently  very 
great,  however,  and  one  elicits  the  sense  of  crepitation 
under  the  palpating  finger.  The  history  is  that  of  a 
wound  received  twenty-four  to  forty-eight  hours  before. 
The  arm  is  reddened  and  the  swelling  is  increasing 
rapidly.  Upon  incision,  free  fluid,  non-bloody,  is  seen, 
and  from  between  the  blanched  muscles  the  gas-laden 
serum  can  be  evacuated.  Following  free  opening  the 
extension  stops. 

In  the  severer  type  the  evidences  of  systemic  in- 
toxication are  marked.  The  restless  roving  eye,  the 
nervous  movements  of  the  body  and  hands,  the  parched 
tongue,  cold  perspiring  brow,  scanty  high-colored  urine, 
and  running  pulse  are  evident. 


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378  ERYSIPELAS,  ERYSIPELOID,  ANTHRAX 

Locally  the  evidences  of  severe  infection  are  marked. 
While  the  gaseous  crepitation  may  not  be  any  more 
marked,  and,  indeed,  it  is  often  less  so,  yet  to  it  is 
added  the  livid  or  blackish  color  suggestive  of  im- 
pending gangrene ;  the  epidermis  may  be  raised  in  blebs 
filled  with  a  dark  bloody  fluid,  the  skin  is  hard,  and 
incision  evacuates  a  reddish  or  brownish  fluid,  foul- 
smelling,  and,  as  a  rule,  containing  gas.  The  muscles 
may  begin  to  show  the  evidence  of  oncoming  gangrene, 
while  the  subcutaneous  and  intermuscular  tissue  may 
have  already  become  necrotic.  The  process  continues 
to  spread  rapidly  in  spite  of  the  incisions.  The  arm 
becomes  gangrenous  and  the  patient  rapidly  succumbs 
to  the  toxemia,  sometimes  in  from  four  to  five  days. 

The  prognosis  depends  upon  the  type  and  the 
promptness  of  treatment.  As  our  experience  grows  it 
is  probable  that  we  will  be  enabled  to  apply  the  proper 
treatment  earlier,  and  in  certain  cases  demand  ampu- 
tation more  promptly,  and  thus  reduce  the  mortality, 
which  now  varies  from  30  to  55  per  cent,  according 
to  various  authorities.  Personally,  of  my  three  cases 
one  recovered  and  two  died.  One  of  these  two  was 
seen  too  late  for  any  hope  of  relief. 

If  we  could  but  differentiate  the  types,  clear  indica- 
tions for  treatment  could  be  placed.  Unfortunately, 
this  is  not  the  case.  The  milder  type  of  infection  due 
to  the  Bacillus  aerogenes  capsulatus  can  often  be  cured 
by  wide  incisions  draining  every  focus.  This  includes 
separating  the  muscular  masses  if  necessary,  washing 
out  the  areas  with  peroxide  of  hydrogen  or  oxygenated 
water,  and  inserting  gauze  drainage  to  prevent  the 
collapse  of  the  openings  and  thus  giving  the  anaerobic 
bacteria  an  opportunity  for  further  development.  The 
cutaneous  incisions  should  be  extensive  and  left  un- 
sutured.  If  under  this  treatment  there  is  any  tendency 
to  spread  in  the  next  twelve  hours,  amputation  should 


.INT  II  R.I  X  379 

\)v  aci\is(.'(l.  riu'  same  ad\  iti-  should  be  tiixc-n  in  ihc 
mure  virulent  type  as  shown  by  the  local  and  systemic 
reaction.  Here  no  time  should  be  wasted  in  palliative 
measures,  for  the  patient  rapidl>  passes  into  the  stage 
of  systemic  infection  or  toxemia,  from  which  he  will 
not  recover  even  with  amputation.  One  may  sa>', 
therefore,  that  amputation  should  be  performed  in 
case  of  doubt.  It  should  be  done  well  proximal  to  the 
infection,  so  as  to  make  incisions  in  healthy  tissue,  and 
the  stump  should  be  left  open  for  secondary  suture 
after  we  are  certain  that  the  process  is  under  control. 
My  own  experience  in  three  cases  bears  out  these 
statements.  In  the  hrst  case  seen,  amputation  was 
performed  at  once  and  the  patient  recovered  promptly. 
The  gaseous  infection  had  spread  well  into  the  arm. 
The  amputation  was  performed  at  the  upper  third  of 
the  humerus.  In  the  second  case  seen  in  consultation, 
wide  incisions  were  made  which  were  further  increased 
upon  the  next  da}-.  The  patient  was  not  seen  by 
me  subsequent  to  the  first  da}'.  I  am  informed,  how- 
ever, that  the  gaseous  infections  subsided,  and  a  sec- 
ondary infection  began  from  which  the  patient  suc- 
cumbed at  the  end  of  three  weeks.  The  third  case 
seen  by  me  was  one  in  which  the  patient  had  suffered 
a  slight  abrasion  of  the  middle  finger  of  the  left  hand. 
I  saw  him  at  the  end  of  the  fifth  day  when  the  systemic 
condition  showed  the  patient  to  be  suffering  from  a 
marked  toxemia.  The  whole  arm  has  a  bluish-black 
color,  is  swollen,  and  covered  by  blebs.  The  arm  was 
amputated  by  an  able  surgeon  at  once,  but  the  patient 
succumbed  from  his  toxemia  within  a  few  hours. 

ANTHRAX 

Anthrax  is  not  common  in  the  United  States,  al- 
though sporadically  it  may  appear  in  various  sections. 
The  frequency'  of  lesions  upon  the  hand  and  arm  is 


380  ERYSIPELAS,  ERYSIPELOID,  ANTHRAX 

given  by  Koch  in  a  series  of  923  cases  as  40  per  cent. 
Keen  has  described  a  typical  case  in  the  Annals  of 
Surgery  of  August,  1905.  Personally,  my  experience 
is  limited  to  one  case  seen  during  my  interneship  at 
the  Cook  County  Hospital.  The  description  of  the 
condition  which  I  append  is  modified  from  that  given 
in  Frazier's  excellent  description  of  the  disease.  No 
attention,  of  course,  is  here  given  to  the  pulmonary  and 
intestinal  types.  When  the  disease  is  implanted  upon 
the  hand  or  forearm  of  those  having  to  deal  with 
hides  and  other  sources  of  infection,  we  note  an  elevated 
pustule,  5  mm.  to  several  centimeters  in  diameter,  with 
a  depressed  central  scab.  The  corium  and  papillary 
body  become  infiltrated  with  a  serocellular  exudate 
and  with  bacilli.  The  perivascular  and  connective- 
tissue  spaces  become  filled  with  leukocytes,  and  the 
pressure  of  this  serous  and  cellular  infiltrate,  together 
with  the  toxins  of  the  bacteria,  cause  the  central 
coagulation  necrosis,  though  suppuration  does  not 
occur  unless  there  is  a  mixed  infection.  When  the  sero- 
cellular exudate  extends  upward  to  the  superficial 
epithelium,  it  elevates  the  latter  and  produces  the 
typical  vesiculation.  In  the  edematous  variety  the 
swelling  is  due  to  the  diffuse  serocellular  infiltrate 
and  to  the  effect  of  the  bacteria  blocking  or  inducing 
coagulation  in  the  capillary  vessels. 

The  lesion  may  be  transferred  to  other  parts  of  the 
arm  or  body,  especially  the  face,  by  scratching  the 
lesion  and  then  the  secondarily  infected  part.  Wher- 
ever the  lesion  occurs  we  note  that  from  a  few  hours 
to  some  days  after  the  inoculation  some  itching  and 
burning  are  felt,  and  upon  inspection  a  small  papule 
with  a  central  bluish  point  is  seen.  A  few  hours  later 
the  papule  becomes  vesiculated,  contains  a  brownish, 
sanguineous  fluid,  and  may  be  scratched  off  by  the 
patient.  The  surrounding  tissues  become  red,  in- 
durated, and  puffy,  and  later  purplish  and  gangrenous 


AMIIR.IX  :{.sl 

ill  appcai-aiuH',  allli()iii;Ii  lluTc  may  be  no  iiidicalion  (jf 
sui)j)urati()n.  Pain  now  ceases,  and  beycHicl  malaise, 
nausea,  slic^ht  fever,  and  muscular  or  joint  pains,  there 
may  be  no  other  constitutional  effect.  A  vesicular 
areola  limited  in  extent  is  soon  observed  about  the 
pustule,  containing  serohemorrhagic  fluid;  the  pustule 
ma}'  undergo  necrosis,  the  area  of  necrosis  rarely  ex- 
ceeding 3  cm.  in  diameter.  In  about  ten  days,  in 
favorable  cases,  a  line  of  demarcation  forms  about  the 
eschar,  which  "floats  off,"  leaving  a  defect  to  heal 
by  granulation.  In  more  severe  cases  the  edematous 
swelling  about  the  pustule  may  be  very  extensive  and 
erysipelatous  in  appearance,  associated  with  a  lym- 
phangitis and  lymphadenitis  with  hard  and  tender 
lymph  nodes.  The  vesicles  become  bullae,  contain  a 
bloody  fluid,  and  the  ultimate  suppurative  and  gan- 
grenous process  may  involve  areas  as  large  as  the  entire 
half  of  the  face.  In  these  severe  cases  the  constitu- 
tional symptoms  are  marked,  resembling  those  of 
cholera,  with  great  prostration  and  depression,  a  weak, 
rapid  pulse,  often  icterus,  diarrhea,  delirium,  and  coma. 

In  the  parts  where  there  is  considerable  loose  areolar 
tissue,  as  the  eyelids,  neck,  and  forearm,  great  edema 
may  be  seen.  Here,  instead  of  the  characteristic 
changes  described  above,  the  area  may  have  a  well- 
defined  border  without  vesiculation,  redness,  or  gan- 
grene. There  may  be  little  or  no  pain,  even  in  those 
cases  ending  fatally. 

The  diagnOvSis  must  be  made  from  the  furuncles  and 
carbuncles.  The  careful  surgeon  will  at  once  note  that 
the  lesion  is  essentially  different  from  these,  and  will 
by  smears  and  culture  determine  the  presence  of  the 
anthrax  bacillus. 

The  statistics  as  to  the  mortality  vary  greatly,  being 
from  6  to  30  per  cent.  Koch  collected  1413  published 
cases,  with  a  m(jrlalit\'  of  32  per  cent. 

Frazicr  summarizes  the  treatment  as  follows: 


382  ERYSIPELAS,  ERYSIPELOID,  ANTHRAX 

To  judge  from  the  experience  of  those  who  are  most 
quaHfied  to  speak,  the  treatment  of  anthrax  should 
consist  essentially  in  the  administration  of  Sclavo's 
serum,  in  the  excision  of  the  pustule,  and  in  the  appli- 
cation of  certain  bactericidal  agents.  The  serum  should 
be  administered  subcutaneously  and  the  pustule  should 
be  excised  only  when  the  surrounding  tissues  are  not 
very  edematous,  taking  the  precaution  to  cauterize  the 
exposed  surfaces  with  carbolic  acid  or  the  actual 
cautery.  If  the  edema  is  marked,  absolute  rest  of  the 
part  should  be  enjoined  and  local  hot  antiseptic 
fomentations,  such  as  bichloride  of  mercury,  applied. 
The  serum  has  no  deleterious  effects,  and  in  the  hands 
of  its  originator  and  others,  especially  in  Italy  and 
England,  the  results  substantiate  the  claims  which 
have  been  made.  It  assists  in  the  destruction  of  the 
bacilli,  before  they  become  so  numerous  that  their 
destruction  by  the  bodily  defences  increases  the  danger 
of  fatal  poisoning  from  the  toxins  set  free  by  the  dis- 
integration of  the  bacilli.  When  the  serum  cannot  be 
obtained,  and  when  excision  is  impracticable,  injections 
of  carbolic  acid  (5  per  cent.)  should  be  tried,  introducing 
the  needle  at  several  points  along  the  margin  of  the 
pustule  and  infiltrating  the  base  of  the  pustule  and 
surrounding  healthy  tissue.  These  injections  may  be 
repeated  frequently.  The  constitutional  symptoms 
must  be  met  by  appropriate  and  supportive  measures. 

It  has  been  my  fortune  to  meet  with  only  one  case 
of  anthrax.  That  occurred  in  a  man,  aged  thirty-five 
years,  who  worked  in  the  Chicago  stockyards.  He 
applied  at  the  Cook  County  Hospital  for  treatment, 
and  I  regret  to  say  that  the  records  of  the  case  cannot 
be  secured  at  the  present  time.  The  lesion  was  upon 
the  left  forearm  and  presented  the  characteristic  gan- 
grenous centre.  He  was  treated  by  local  antiseptics 
and  made  a  prompt  recovery. 


SECTION   V 

COMPLICATIONS  AND  SEQUEL/5^:  OF  INFECTIONS 
OF  THE  HAND 


CHAPTER    XXVI 

FOREARM   INVOLVEMENT  FROM   INFEC- 
TIONS OF  THE  HAND— PATHOLOGY 
AND  DIAGNOSIS 

Forearm  involvement  occurs  in  two  forms — that 
associated  with  lymphangitis  and  that  following  tendon- 
sheath  infection  of  the  flexor  tendons  and  abscesses 
in  the  palm.  These  two  forms  have  been  touched  upon 
in  general  in  discussing  these  infections  in  the  preceding 
chapters.  The  patholog}'  and  localization  is  essentially 
different,  as  it  arises  from  the  two  sources.  I  refer,  of 
course,  to  suppurative  involvement,  and  have  no  refer- 
ence to  the  edema  w^hich  always  occurs  with  any 
infection.  At  the  risk  of  some  repetition,  I  shall 
review  the  subject  in  general,  so  as  to  give  a  composite 
picture. 

SUBCUTANEOUS  ABvSCESSES 

That  form  due  to  lymi:)hatic  involvement  of  super- 
ficial origin  has  been  referred  to  on  page  318.  We  ma>- 
have  a  secondary  involvement  upon  both  the  flexor 
and  extensor  surfaces.  Upon  the  flexor  surface  we  hnd 
a  localization  just  above  the  annular  ligament  in  man\- 
cases  of  dee])  infection  of  the  hands.  i)articularh-  those 
acses  showing  an  ulnar  bursitis.     The\'  are  character- 


384  FOREARM  INVOLVEMENT 

ized  by  redness  and  slight  induration  over  an  area  two 
or  three  inches  in  length  at  the  lower  end  of  the  fore- 
arm. The  diagnosis  is  not  difficult,  the  only  thing  to 
be  borne  in  mind  being  that  the  surgeon  should  under- 
stand its  origin  and  should  not  desist  from  dealing  with 
the  extension  under  the  tendons  from  a  rupture  of 
its  synovial  sheath,  since  there  is  no  connection  be- 
tween these  pockets,  and  draining  the  superficial 
pocket  does  not  drain  the  deeper  and  more  important 
focus. 

Besides  this  well-differentiated  localization,  small  foci 
may  develop  along  the  lines  of  any  lymphatic,  either 
on  the  flexor  or  dorsal  surface.  Care  should  be  taken 
not  to  mistake  these  uncommon  localizations  for  the 
acute  non-suppurative  inflammation  of  the  lacunae 
(see  p.  319).  Again,  localizations  may  take  place 
about  the  glands  of  the  epitrochlear  region,  as  has 
been  described  in  Chapter  XX. 

The  most  important  subcutaneous  accumulation 
associated  with  lymphatic  infection  occurs  upon  the 
dorsum  of  the  forearm.  This  condition,  characterized 
by  a  brawny  induration  of  the  entire  dorsum,  with 
necrosis  and  sloughing  of  the  subcutaneous  tissue,  is 
one  of  the  gravest  complications  met  with  in  hand 
infections.  A  full  discussion  may  be  found  in  Chapters 
XX  and  XXI. 

DEEP  ABSCESSES 

The  deep  involvement,  no  matter  what  the  origin, 
almost  always  is  found  upon  the  flexor  surface.  This 
most  commonly  arises  through  extension  by  rupture 
of  the  proximal  end  of  the  ulnar  or  radial  bursse  or  by 
extension  from  a  palmar  abscess.  This  is  by  all  odds 
the  most  important  question  we  have  to  deal  with 
when  considering  forearm  involvement.  It  will  be 
discussed  under  three  heads; 


JBSCESS  FORMATION  JriTIIOVT  COMrfJCtTIOAS     :IS5 

1.  Cases  showing  forearm  abscesses  without  other 
complications. 

2.  Cases  showing  forearm  involvement  with  carpal 
joint  involvement. 

3.  Cases  showing  forearm  invohenient  with  second- 
ary hemorrhage. 

Forearm  Involvement:    Abscess  Formation  without  Other 
Complications 

Location  of  the  Abscesses. — It  has  been  the  habit 
of  surgeons  and  writers  dealing  with  this  subject  to 
speak  of  these  abscesses  in  a  general  way  only,  and  to 
suggest  drainage  through  the  volar  surface  between  the 
tendons  and  muscles.  In  my  earlier  cases  I  was  struck 
with  the  long  convalescence,  the  repeated  incisions,  and 
the  inadequate  drainage  owing  to  the  rapid  closure  of 
the  sinuses  through  the  muscular  bodies.  Therefore  a 
careful  study  of  the  anatomy  of  the  forearm  was  under- 
taken both  by  dissection  of  serial  sections  and  by  experi- 
mental injections  made  through  the  various  tendon 
sheaths  and  from  other  sites  of  predilection  of  pus  in 
the  hand.  By  this  I  determined  the  probable  site  of 
these  secondary  abscesses  in  the  forearm.  These  experi- 
mental and  anatomical  deductions  were  verified  by  a 
study  of  all  my  cases  showing  this  complication,  as  well 
as  an  extensive  review  of  cases  reported  in  the  litera- 
ture. The  result  was  beyond  expectation.  The  study 
enables  the  surgeon  to  prognosticate  before  operation 
the  exact  location  of  pus  in  the  forearm.  It  suggested 
new  sites  for  drainage  which  cured  cases  in  from  one  to 
two  weeks  by  two,  or  at  most  three,  primary  incisions, 
which  by  the  older  procedures  would  have  required  from 
three  to  five  weeks,  with  the  probability  of  man>'  com- 
plications. 

The    anatomical    and    experimental    work    I    have 

detailed  in  Chapter  X.     It  remains  for  me,  therefore,  to 
25 


386  FOREARM  INVOLVEMENT 

adduce  the  clinical  proof  of  its  correctness  and  suggest 
plans  of  treatment.  It  will  be  seen,  by  referring  to 
Chapter  X,  that  the  final  deduction  made  from  the 
researches  was  that  the  important  space  in  which  pus 
would  be  found  in  those  cases  where  the  infection 
originated  in  the  hand  had  the  following  boundaries: 
It  lies  under  the  flexor  profundus  digitorum  tendons 
and  muscle.  About  three  inches  up  on  the  forearm  the 
pus  begins  to  invade  the  intermuscular  septa,  passing 
first  to  the  area  about  the  median  nerve  and  later  to 
the  area  about  the  ulnar  artery  and  nerve.  Here  it 
lies  between  the  flexor  carpi  ulnaris  and  the  flexor  pro- 
fundus. This  is  about  four  inches  up  on  the  forearm. 
From  here  it  may  pass  toward  the  elbow  along  the 
vessels  and  nerves,  particularly  the  median  nerve,  or 
more  commonly  it  may  extend  distally  along  the  ulnar 
artery  under  the  flexor  carpi  ulnaris  and  appear  sub- 
cutaneously  about  three  inches  up  on  the  ulnar  side. 
It  may  extend  downward  along  the  radial  artery,  but 
this  is  certainly  an  uncommon  termination.  The  largest 
part  of  the  space  is  about  two  inches  above  the  wrist. 
Its  most  superficial  parts  are  on  either  side  just  volar 
to  the  ulna  and  radius.  The  floor  of  the  space  is  made 
up  by  the  pronator  quadratus  at  the  wrist  and  the 
interosseous  septum  above.  The  space  may  hold  a  half- 
pint  or  more  of  fluid.  No  other  well-defined  space  is 
present  except  that  comprising  the  subcutaneous  tissue. 
In  corroboration  of  this  statement,  I  shall  report  in 
brief  cases  that  have  come  under  my  observation,  and 
shall  add  a  few  from  the  reports  of  Tornier  and  Forssell 
to  show  that  my  deductions  are  unbiassed.  That  there 
may  be  no  question  as  to  the  possibility  of  the  infection 
having  arisen  sequentially  from  a  carpal-joint  involve- 
ment, those  cases  will  be  excluded  and  only  uncompli- 
cated forearm  involvement  discussed.  Altogether  I 
have  now  had  26  cases  showing  this  extension.    The 


ABSCESS  roRM.irioS    ir/TJIOi'T  COM  I' LICIT  IONS     :\Wt 

rcj^urt  ul  Lhc  ijoslnioilcm  in  C^asc  XXII  nia>'  alscj  be 
noted  in  corroboration. 

Case  XXV. — The  ulnar  bursa  was  opened  and  inci- 
sion extended  to  the  middle  of  (he  forearm  which 
cx]){)sed  an  abscess  lyiiiL;  mainh  under  the  flexfjr 
pnjfundus  digitorum. 

Case  XXVI. — The  llexcjr  side  of  the  forearm  was 
swollen  and  j)ainful  to  the  upper  third,  incision  was 
continued  from  the  ulnar  bursa  on  the  forearm  toward 
the  centre.  In  juxtaposition  to  the  nerves  and  blood- 
vessels a  pocket  of  pus  was  evacuated,  w^hich  extended 
between  the  flexor  sublimis  digitorum  and  the  flexor 
profundus  digitorum,  and  lying  on  the  interosseous 
membrane  of  the  upper  half  of  the  forearm. 

Case  XX\'II. — The  hand  and  forearm  w-ere  swollen, 
incision  was  extended  from  the  ulnar  bursa  in  the  fore- 
arm and  the  flexor  muscles  w^ere  separated  by  the  handle 
of  the  scalpel.  The  abscess  extended  along  the  inter- 
osseous ligament  to  within  a  hand's  breadth  of  the 
elbow. 

Case  XXVIII. — Incision  was  made  opening  the 
sheath  of  the  flexor  longus  pollicis  and  up  to  the  annular 
ligament;  a  second  incision  was  made  into  the  same 
sheath  above  the  annular  ligament,  and  this  was 
extended  along  the  lower  half  of  the  forearm  over  the 
radial  sources  of  the  flexor  sublimis  digitorum.  Pus 
was  found  along  the  flexor  longus  pollicis  and  behind 
the  flexor  profundus  digitorum  in  the  lower  third  of  the 
forearm. 

Case  XXIX. — A  large  amount  of  pus  was  shown  in 
the  lower  two-thirds  of  the  forearm  lying  between  the 
flexor  sublimis  digitorum  and  the  flexor  carpi  ulnaris, 
below  the  flexor  profundus,  which  was  entirely-  evacu- 
ated by  a  single  incision  upon  the  ulnar  side  above  the 
w  rist -joint . 

In    (he  following;  case  tliere  was  a   neglected   tendon 


388  FOREARM  INVOLVEMENT 

sheath  infection  on  the  dorsum.  These  cases  are  ex- 
tremely uncommon,  since  they  are  generally  only  local 
abscesses  without  extension. 

Case  XXX. — An  infection  extended  upon  the  back 
of  the  forearm ;  after  two  superficial  abscesses  had  been 
opened,  it  was  noted  some  days  later  that  there  was 
a  painful  swelling  on  the  dorsal  ulnar  side  of  the  fore- 
arm; this  was  incised  as  far  as  the  fascia  without  free- 
ing any  pus.  A  pocket  was  found,  however,  under  the 
dorsal  annular  ligament  extending  into  the  otherwise 
healthy  muscle  above. 

Case  XXXI  (Forssell). — A  large  incision  was  made 
on  the  middle  of  the  forearm  down  to  the  palm,  cutting 
the  anterior  annular  ligament  and  part  of  the  palmar 
aponeurosis,  a  large  abscess  was  found  in  the  palm  and 
under  the  annular  ligament  and  in  the  forearm  lying 
between  the  ulnar  muscles  and  the  flexor  profundus 
digitorum.     The  tendon  sheaths  were  entirely  intact. 

Case  XXXII  (Forssell). — About  a  week  after  the 
primary  injury  there  was  an  increase  of  pain  in  the  arm, 
which  became  red,  sensitive,  and  swollen.  After  four 
or  five  days  pus  was  forced  out  by  pressure  on  the 
forearm,  a  7  cm.  cut  was  made  above  the  wrist  through 
the  skin,  followed  by  a  blunt  dissection  to  the  tendon 
sheaths,  from  which  thin  pus  was  evacuated,  drain 
was  inserted  through  this  opening  under  the  annular 
ligament  out  through  the  hand. 

On  the  ulnar  side  of  the  forearm  an  incision  was 
made,  15  cm.  long,  carried  down  between  the  flexor 
profundus  digitorum  and  the  flexor  carpi  ulnaris;  pus 
was  met  with  here  and  the  tendons  of  the  flexor  pro- 
fundus digitorum  were  surrounded  with  pus  in  the 
lower  three-fourths  of  the  forearm. 

Case  XXXIII  (Tornier). — Two  weeks  after  injury 
it  was  noticed  that  the  entire  arm  was  swollen,  espe- 
cially the  forearm.     On  the  same  day  the  ulnar  bursa 


ABSCESS  FORM.rriON  jiiriiovT  coMPi.ic.rrioAs    :!.S9 

was  opened,  a  lar.uc  amoiiiil  nl  |)iis  was  loiiiul,  iniK  li 
burrow  iiiu,  Ix-hind  the  imisclcs  ol  (he  lorcarin,  and  wide 
incisions  were  made  here. 

Case  XXXIV  (Forssell).— The  lower  third  of  the 
forearm  was  swollen  and  tender,  but  the  patient  had 
no  spontaneous  pain.  The  uhiar  bursa  was  opened 
throughout  its  length  and  the  incision  continued  over 
the  low^er  third  of  the  forearm.  This  exposed  an 
abscess  lying  on  the  interosseous  membrane  under 
the  muscles.  Counterincisions  were  made.  Culture 
showed  streptococcus. 

Case  XXXV  (Tornier). — Incision  was  made  into 
the  radial  bursa  and  on  the  forearm  extending  on  the 
radial  side,  exposing  an  abscess  lying  between  the 
pronator  radii  teres  and  the  flexor  carpi  radialis,  behind 
the  deep  flexors. 

Case  XXXVI  (Tornier). — Both  bursae  opened, 
anterior  annular  ligament  incised,  large  amount  of 
thick  yellowish-green  pus  was  found  in  the  lower  part 
along  the  interosseous  membrane. 

From  these  studies  it  is  certainly  justified  to  outline 
the  position  of  these  secondary  abscesses  as  we  have. 
The  position  of  the  pus  at  a  point  one  and  one-half 
inches  up  on  the  forearm  is  shown  in  cross-section 
(Fig.  io8),  and  also  the  position  of  the  pus  when  it 
reaches  the  middle  of  the  arm  is  shown  in  a  second 
cross-section  (Fig.   109). 

Symptoms,  Signs,  and  Diagnosis. — The  diagnosis 
of  a  forearm  involvement  is  based  on  the  knowledge 
of  an  associated  tendon-sheath  infection  of  the  ulnar 
or  radial  bursae  or  a  middle  palmar  infection  and  the 
signs  incident  to  the  development  of  any  deep  abscess. 
Especially  in  an  ulnar  bursitis  which  has  existed  two  or 
more  days  before  drainage  do  we  look  for  a  beginning- 
forearm  involvement.     In  any  case,  we  have  the  de\el- 


390 


FOREARM  INVOLVEMENT 


opment   of   increased   swelling   of   the   forearm.      The 
swollen  part  has  not  the  soft  feeling  incident  to  edema, 


Fig.  io8 


^^ 

^^ 

"'"J^ 

^kr 

'^3 

i3'' 

^^JHlHIll 

HM^v^' 

^^^ 

^ 

Photograph  of  cross-section  7  cm.  below  the  radial  styloid,  showing  area 

filled  with  pus. 

Fig.  109 


Photograph  of  forearm  just  below  the  middle,  showing  position  of  pus  in 
its  relation  to  the  ulnar  artery  and  the  median  nerve. 

but  a  full  tense  feeling  as  if  the  forearm  were  an  over- 
distended  bag.  There  may  be  but  little  increase  in 
redness.      The   induration   seen   in   subcutaneous   ab- 


INVOLVEMENT  IllTll  JfRIST- JOINT  INV.ISION      .''.91 

scesses  will  l)i'  ahsfiil.  I  lowcx  t-r,  Iciulcnicss  to  (Ic<-|) 
pressure  is  increased.  I'he  wrist  becomes  more  or  less 
fixed  and  the  careful  observer  has  no  difficult}'  in  sug- 
gesting the  diagnosis  on  the  history  of  these  findings. 
Of  course,  later,  when  the  pus  had  infiltrated  every 
part,  e\'en  the  novice  can  make  the  diagnosis.  Early 
diagnosis  is  greatly  to  be  desired,  however.  It  should 
be  urged  that  in  case  of  doubt  incision  may  be  made 
after  the  manner  already  suggested,  by  lateral  incisions, 
without  in  any  way  jeopardizing  the  patient's  forearm. 
Whenever  I  open  an  ulnar  or  radial  bursa,  and  there  is 
any  question  in  my  mind  as  to  forearm  involvement,  the 
forearm  incisions  are  made.  Indeed,  these  same  inci- 
sions may  be  used  to  drain  the  upper  end  of  the  sheaths 
in  the  forearm.  So  that  the  incisions  thus  serve  two 
purposes — they  drain  the  bursae,  and  if  pus  is  already  in 
the  forearm  or  develops  subsequently,  they  afford  it  an 
immediate  outlet. 


Deep  Forearm  Involvement  Associated  with  Wrist-joint 

Invasion 

If  operated  upon  early  the  involvement  of  the  wrist- 
joint  will  be  uncommon.  In  certain  cases,  however,  it 
will  be  met  with  either  early  in  the  course  or  later  as 
a  complication.  The  wrist-joint  involvement  is  a  most 
serious  complication,  and  it  should  be  watched  for, 
particularly  in  aged  patients  w^ith  involvement  of  the 
radial  bursa  (tendon  sheath  of  the  flexor  longus  pollicis). 
By  reference  to  the  cases  it  will  be  seen  that  of  the 
8  cases  here  reported,  7  were  fifty-four  years  of  age  or 
older.  It  is  to  be  noted  particularly,  however,  that 
every  case  was  one  of  involvement  of  the  radial  bursa, 
either  alone  or  in  conjunction  with  other  foci.  In  5, 
the  primary  process  was  in  the  thumb.  One  cannot 
help  but  feel  that  this  is  more  than  a  coincidence;  as 


392  FOREARM  INVOLVEMENT 

yet,  however,  no  definite  anatomical  reason  can  be 
adduced  to  explain  it.  In  none  of  my  injections  of  this 
synovial  sheath  has  the  mass  ruptured  or  extended 
into  the  wrist-joint. 

Examination  of  the  Radial  Bursa  in  Cadavers. 
— To  determine  whether  or  not  there  is  at  times  a 
normal  opening  connecting  the  radial  bursa  and  the 
wrist-joint,  with  the  assistance  of  Prof.  P.  T.  Burns 

Fig.  iio 
5     OM  05C5 


PMP5 


Drawing  showing  intimate  relation  of  the  ulnar  bursa  to  the  os  magnum 
and  its  early  involvement.  Notice  the  association  of  the  radial  bursa  and 
the  trapezium :  S,  sinus ;  OM,  os  magnum :  IP  MPS,  infected  process  leading 
from  middle  palmar  space;  lUB,  infected  ulnar  bursa;  RB,  radial  bursa. 

and  Dr.  A.  T.  Horn,  of  the  Anatomical  Department 
of  the  Northwestern  University  Medical  College,  I 
have  examined  30  cadavers,  and  in  no  one  of  them 
have  we  found  any  normal  opening,  although  Prof. 
Burns  states  that  he  has  at  times  noted  such  a  com- 
munication. This  is  borne  out  by  other  observers, 
but  it  must  be  extremely  rare.  According  to  Schwartz, 
the  parietal  layer  of  the  ulnar  bursa  is  attached  to  the 


INJ-()LJKMKM-  iriTII  JfRIST  JOINT  INVASION      393 

ligamcnls  and  pcn'ostciiin  ol  the  caipal  hoiu-s,  par- 
ticiiIarK  llu'  imciloini  and  os  inaL;iuini.  I'OrsscIl  stales 
that  in  cases  of  rari)al  inxolvement  he  has  noted  that 
the  OS  maiiiunii  suffers  the  greatest  destruction  (¥\g. 
no). 

Pathology  Found  in  Serious  Wrist-joint  In- 
volvement.— Since  my  own  experience  with  this  con- 
dition is  rare,  I  have  been  compelled  to  turn  to  the 
literature  for  reports  of  postmortems.  Of  my  personal 
cases,  4  in  number,  all  recovered.  One  case  (Sable) 
is  found  in  the  chapter  dealing  with  Osteomyelitis. 
Owing  to  the  seriousness  of  this  complication,  one  may 
be  pardoned  for  making  rather  complete  reports. 

In  the  first  case  the  position  of  the  sinus  openings 
on  either  side  above  the  annular  ligament  at  the  site 
of  the  two  vessels  emphasizes  the  tendency  of  these 
abscesses  to  follow  the  vessels  (see  Experiment  47, 
where  the  only  place  the  mass  became  subcutaneous 
was  on  the  ulnar  side  just  above  the  annular  ligament). 
The  absence  of  tenderness  and  pain  about  the  necrotic 
joint  is  also  worthy  of  note.  The  involvement  of  the 
radio-ulnar  joint,  as  here  noted,  is  a  frequent  complica- 
tion. 

Case  XXXVII  (Bauchet). — Deep  phlegmon  of  the 
right  thumb;  deep  phlegmon  of  the  hand;  phlegmon 
of  the  forearm;  fistulous  processes;  abundant  suppura- 
tion. Great  scar  over  the  sacrum;  septic  infection. 
Death.      Postmortem. 

This  man,  between  fifty- five  and  sixty  years  old, 
gives  a  history  of  an  inflammation  of  the  thumb  two 
months  before  entrance.  On  the  forearm  there  are 
two  openings;  one  is  at  the  inside  and  the  other  at  the 
outside  of  the  anterior  surface;  both  are  about  4  cm. 
from  the  radiocarpal  joint.  These  two  openings  are 
longitudinal,  about  2  cm.  long,  with  edges  grayish 
and  fungous.     At  the  level  of  the  first  phalanx  of  the 


394  FOREARM  INVOLVEMENT 

thumb  one  sees*  the  scar  of  a  former  purulent  focus. 
No  redness;  dorsal  aspect  of  the  hand  shows  no  tume- 
faction; no  sinuses.  Tenderness  to  pressure  is  not 
very  acute;  the  wrist  is  neither  swollen  nor  painful. 
By  pressing  on  the  palm  of  the  hand  or  on  the  lower 
part  of  the  forearm,  one  causes  a  notable  quantity  of 
whitish,  poorly  mixed,  fluid  pus,  without  a  bad  odor, 
to  flow  out  through  the  openings  already  mentioned. 
The  probe  introduced  through  these  openings  slides  a 
considerable  distance  along  the  lower  layers  of  the 
forearm,  but  meets  no  denuded  portions  of  the  bone. 

Aside  from  the  two  openings  already  mentioned, 
one  notes  still  farther  inward,  at  the  level  of  the  upper 
third  of  the  anterior  surface,  a  small  opening  from  which 
pus  escapes,  but  in  smaller  quantity  than  from  the 
other  two  openings. 

By  pressing  the  ulna,  the  radius,  and  at  the  same 
time  trying  to  make  the  patient  move  the  wrist,  one 
notes  a  grating  between  the  ulna  and  the  radius  and 
between  these  bones  and  those  of  the  wrist,  which 
resembles  nothing  more  than  two  nuts  being  rubbed 
together. 

Diagnosis. — Deep  whitlow  of  the  thumb;  extension 
of  inflammation  into  the  great  common  synovial  sheath 
of  the  tendon  of  the  little  finger;  rupture  of  the  focus 
between  the  muscular  layers  of  the  forearm,  but  more 
especially  of  the  deeper  part;  extension  of  the  suppura- 
tion to  the  carpal  joints;  necrosis  of  the  bones. 

Postmortem. — The  tendons  are  fixed  in  an  invariable 
position,  and  to  free  them  it  is  necessary  to  cut  out  the 
resisting  fibrous  adhesions.  These  changes  are  evident 
in  the  palm  of  the  hand,  under  the  annular  ligament, 
and  the  lower  part  of  the  forearm,  all  along  the  syno- 
vial sac.  These  changes  extend  to  the ,  ends  of  the 
tendons  of  the  thumb  and  little  finger.  They  stop 
slightly  above  the  metacarpophalangeal  joints  of  the 


IM-OIJKMF.Sr  Uiril  IIRlST-JOfXT  INVASION      395 

iiickw,  middle,  and  riiii;  liiii^ers.  Aloiii;  llu'se  lingers 
the  synovial  sheaths  and  thi'  tendons  are  absolutely 
intact.  The  large  focus,  black  and  i)urulent,  has  an 
exit  in  the  two  openings  before  menti(jned.  At  the 
upper  and  outer  part  it  is  closed,  and  the  muscles  of 
the  forearm  on  this  side  are  healthy.  On  the  ulnar 
sid(\  on  the  contrary,  the  fibrosynovial  sac  is  frayed, 
and  the  jnis  has  spread  to  the  level  of  the  upper  part 
of  the  forearm,  between  the  deep  and  superficial 
muscular  layers.  This  purulent  focus,  formed  by  a 
rupture  of  the  vSynovial  sheath,  has  its  exit  in  the  smaller 
opening,  which  has  already  come  under  discussion. 

The  joints,  radiocarpal,  radio-ulnar,  and  carpal,  are 
open  anteriorly  and  communicate  extensively  with  the 
palmar  purulent  focus,  through  several  openings.  The 
bones  are  neither  red  nor  spotted  nor  crumbling. 
They  are  rather  of  an  ivory-gray  color  and,  in  spots, 
blackish;  there  is  no  false  membrane  or  generative 
abscess  in  the  joint ;  but  the  cartilage  has  been  destroyed, 
almost  entirely  resorbed,  and  has  disappeared;  the 
bones  bared  of  this  cartilage  resemble  bones  which 
have  been  soaked  in  water  for  some  time. 

The  following  case,  reported  in  the  inaugural  dis- 
sertation of  Max  Tornier,  from  the  Grief swald  Clinic 
(Prof.  Helferich),  emphasizes  again  the  frequency  of 
sinus  openings  in  carpal  involvement  at  the  sites  we 
have  mentioned. 

Case  XXXVIII. — Phlegmon  of  the  forearm,  in- 
volvement of  carpal  and  radiocarpal  joints. 

Man,  aged  fift>'-eight  years.  On  the  ulnar  side  of  the 
wrist  there  is  a  sinus  opening  4  cm.  long,  through  which 
a  probe  reaches  down  into  the  wrist-joint.  Under 
narcosis  and  anemia,  Langenbeck's  incision,  the  tendon 
of  the  long  radial  muscle,  infiltrated  with  pus,  was  re- 
sected for  about  8  cm.  Resection  of  the  proximal  line 
of  the  carpal   bones,  between  which   small   masses  of 


396  FOREARM  INVOLVEMENT 

pus  were  found.  Drainage  established.  Very  dilatory 
course;  the  distal  row  of  carpal  bones  sloughed  through 
necrosis.  An  erysipelas  with  numerous  abscesses  on 
the  forearm  made  further  incisions  necessary.  When 
dismissed  the  incisions  were  healed ;  the  wrist  hung  loose. 

The  following  case  from  the  same  report  shows  the 
beneficial  results  of  early  and  radical  operation  in  the 
case  of  wrist-joint  involvement,  and  shows  the  inade- 
quacy of  superficial  incisions  on  the  forearm. 

Case  XXXIX. — Severe  phlegmon  of  the  hand  and 
forearm ;  caries  of  carpal  and  radiocarpal  joints. 

Patient,  aged  sixty-three  years.  Two  weeks  after 
infection,  incision  over  abscess  on  flexor  and  extensor 
sides  of  forearm.  Two  weeks  later,  second  incision 
through  the  intermuscular  spaces  to  the  ligamentum 
interosseum.     Iodoform  drainage.     No  fever  evenings. 

The  probe  in  the  wound  of  the  dorsal  incision  strikes 
carious  bones  of  the  wrist;  it  is  pushed  on  in  the  direc- 
tion of  the  dorsoradial  incision  to  the  wrist-joint. 
The  latter  is  opened,  and  shows  destruction  of  the  car- 
tilage and  the  bone.  The  joint  is  filled  with  pus. 
Resection  of  the  navicular,  semilunar,  trapezium,  and 
trapezoid.  Good  healing  under  Langenbeck's  exten- 
sion bandage.  Good  granulation.  Daily  massage. 
Patient  dismissed  for  a  few  days  and  did  not  return. 

Case  XL,  besides  demonstrating  the  pathology  of 
severe  cases  of  carpal  involvement  and  the  extension 
of  infection  to  this  and  the  forearm,  from  the  tendon 
sheaths,  emphasizes '  the  error  that  often  occurs  in 
mistaking  for  pus  the  enormous  edema  which  is  found 
upon  the  dorsum  in  these  cases  of  palmar  infections. 

Case  XL  (Forssell). — Suppuration  of  the  radial  and 
ulnar  bursae  with  involvement  of  the  radio-ulnar, 
radiocarpal,  and  carpal  joints  and  forearm. 

J.  L.,  aged  fifty-four  years.  Woman.  Pain  in  the 
left  hand  from  no  known  reason ;  three  days  later  visited 


INVOLVEMENT  iriTII  IIR/ST  JO/XT  /.\l\/SION      :',<)7 

li()s|)ital.  Scxcii  (lays  later,  left  hand  (cxccpl  lor  tluiml) 
and  secoiul  and  third  phalanges  of  the  other  f'lngersj 
and  to  a  certain  extent  the  whole  arm  are  swollen; 
pain  over  the  whole  back  of  hand,  more  in  the  palm, 
especially  in  the  fourth  interosseous  space.  Finger 
half  bent;  extension  very  painful.  Temperature, 
100.5°.  Incision  of  the  dorsum  on  the  same  day;  little 
pus.  Incision  along  the  tendon  sheaths  of  the  first 
and  fifth  fingers;  communication  established  between 
this  and  incision  above  the  ligament.  Also  incision 
over  the  flexor  carpi  ulnaris,  with  communication  with 
the  last  mentioned  incision.  Pus  in  large  quantities 
from  all  the  incisions. 

Four  weeks  after  onset  of  infection  the  tendons 
removed  as  far  as  they  appeared  infected.  All  carpal 
bones  removed  with  a  curette  except  the  trapezium 
and  the  upper  part  of  the  third  metacarpal  bone. 

Discharged  after  three  months  with  ankylosis  of 
the  joint  of  the  hand. 

Case  XLI  (Forssell). — Tenosynovitis  of  radial  and 
ulnar  bursae,  with  involvement  of  the  carpus. 

G.  K.,  aged  sixty  years,  January  7,  1S98.  After  a 
small  wound  at  the  end  of  the  thumb,  symptoms  of 
tenosynovitis  in  the  thumb  and  little  finger.  Same  day, 
incision  in  the  tendon  sheath  of  the  thumb. 

January  8.  The  ulnar  bursa  was  completely  cleft; 
incision  into  the  upper  part  of  the  radial  bursa. 

Aside  from  an  insignificant  necrosis  of  the  tluinib 
and  little  finger  tendons,  all  went  well  until  Januar\-  16, 
when  symptoms  of  an  infection  of  the  wrist  arose. 
These  increased,  and  (Januar>-  18)  necessitated  an 
incision  into  the  wrist-joint,  a  considerable  serofibrinous 
secretion  being  found.  Joint  washed  out  with  i  per 
cent,  sublimate  solution.  Gradually  distinct  formation 
of  pus  took  i:)lace,  which  led  to  a  j^artial  resection  of 
the  wrist  (February  5). 


398  FOREARM  INVOLVEMENT 

In  the  following  case  the  decreased  sensitiveness  in 
the  area  of  the  distribution  of  the  median  nerve  serves 
to  emphasize  the  tendency  of  infection  to  spread  along 
that  nerve,  as  demonstrated  in  Experiment  47  and 
shown  in  Fig.  109. 

Case  XLII  (Forssell). — Tenosynovitis  of  the  thumb 
and  little  and  ulnar  bursae.  Phlegmon  of  the  forearm 
and  articulation  between  hand  and  forearm. 

S.  T.,  aged  thirty-three  years,  female.  April  4,  1898. 
Distinct  symptoms  of  suppuration  of  the  carpal  tendon 
sheaths  (tendon  sheath  of  the  little  finger  intact)  and 
on  the  forearm.  Only  slight  pain  on  passive  movements 
of  the  finger;  ''the  finger  twinges;"  the  same  is  true  of 
palpation  of  the  palm  and  the  flexor  side  of  the  forearm. 
Complete  opening  of  the  ulnar  bursa;  by  mistake  the 
sheath  of  the  little  finger  was  opened;  no  pus;  incision 
into  the  thumb;  pus  within  and  without  the  sheath. 

April  1 1 .  Incision  into  the  lower  part  of  the  forearm 
down  to  the  ulna  (burrowing  of  pus).  For  three  days 
there  have  been  symptoms  of  infection  of  the  wrist- 
joint;  pus  pours  from  a  small  hole  in  the  capsule  between 
the  pisiform  and  cuneiform.  Around  the  tendon  of 
the  flexor  longus  pollicis  there  is  much  pus,  wherefore 
an  incision  of  the  same  is  made;  it  was  especially 
necrotic  in  the  region  of  the  carpal  ligament;  here  there 
is  also  necrosis  of  other  tendons. 

April  12.  Much  pus  in  the  wrist  and  upper  arm. 
Several  carpal  bones  removed  under  anesthetic. 

April  16.  Temperature,  102°  to  105°.  Amputation 
of  the  arm.  Examination  of  the  amputated  arm; 
elbow-joint  intact;  all  pus  cavities  opened  except  the 
suppurated  tendon  sheaths  of  the  fourth  and  third 
fingers.  Necrosis  of  all  tendons  at  the  anterior  annular 
ligament;  the  condition  of  the  median  nerve  was  by 
mistake  not  investigated. 

April  17.     Exitus_i2  M, 


isroiJ'EMEsr  11  ITU  urist- joint  infusion    :^99 

Epicrisis. — Wortlix  of  notice  was  the  decreased 
sensitiveness  and  pain  in  the  median  region,  due  prob- 
ably to  the  compression  of  the  nerve.  The  inflamma- 
tion of  the  wrist  was  possibly  due  to  the  infection  of 
the  joint  between  the  pisiform  and  the  cuneiform;  in 
the  cai)sule  of  this  joint  a  certain  defect  was  noted, 
whether  primary  or  secondary,  still  pointing  to  a  cer- 
tain weakness  in  the  boundary  of  the  canal  toward 
the  carpal  canal. 

In  the  subjoined  case  the  wrist  did  not  become  in- 
volved until  fifteen  days  after  the  beginning  of  the 
infection.  In  this  case,  as  in  many  of  the  others 
reported  here,  there  may  be  some  question  as  to 
whether  or  not  the  incisions  were  made  early  enough 
and  at  the  proper  sites.  Throughout  the  literature  it 
is  evident  that  surgeons  have  paid  too  little  attention 
to  the  fascial  pockets  in  which  pus  lies,  confining  their 
attention  almost  entirely  to  the  tendon  sheaths. 

Case  XLIII. — Compound  dislocation  of  thuml). 
Infection  of  radial  and  ulnar  bursae,  resection  of 
necrotic  carpal  bones. 

C.  E.,  aged  fifty-eight  years.  A  large  quantity  of 
grayish-yellow,  thinly  fluid  pus  was  freed  by  opening  the 
radial  bursa.  An  incision  which  had  been  made  on 
the  volar  side  of  the  thumb  lengthened,  and  the  tendon 
cut  out. 

May  20.  (^)mplete  splitting  of  the  ulnar  bursa  and 
the  tendon  sheath  of  the  little  finger;  in  the  bursa  and 
the  tendon  sheath  a  yellowish  fluid  pus.  No  burrowing 
toward  the  forearm  could  be  discovered.  The  swelling 
on  the  hand  went  down.  On  May  24  it  is  especialh- 
noted  that  there  is  no  swelling  around  the  wTist-joint. 
The  superficial  tendons  of  the  little  finger  had  become 
necrotic  just  below  the  carpal  ligament,  and  those  of 
the  fourth  finger  as  well  shcnved  beginning  of  necrosis 
here. 


400  FOREARM  INVOLVEMENT 

May  29.  Temperature,  37.3°  to  37.4°.  Slight  pain 
in  the  hand  near  the  wound  in  the  carpal  region. 
Several  tendons  showed  -  signs  of  necrosis.  On  the 
anterior  side  of  the  wrist,  exposed  bone  (radius,  carpal 
bone?)  can  be  felt. 

June  7.  Temperature,  37.4°  to  38.2°.  Partial 
resection  of  the  wrist-joint.  Removal  of  the  carpal 
bones  except  the  trapezium  and  pisiform;  unciform 
necrotic. 

By  these  cases  I  have  attempted  to  portray  the 
pathology,  symptomatology,  and  course  of  these  fore- 
arm cases,  complicated  by  wrist-joint  involvement. 
The  diagnosis  of  its  occurrence  depends  upon  the 
crepitation  noted  in  the  joint,  associated  with  an 
increase  of  tenderness  and  swelling  about  the  joint. 
It  will  be  remembered  that  the  original  infection  is 
upon  the  flexor  surface.  The  swelling  and  tenderness 
are  here.  When  the  joint  becomes  involved  the  dorsum 
also  partakes  of  this.  Under  normal  conditions  a 
depression  is  noted  on  the  back  of  the  wrist-joint  to 
the  radial  side  of  the  extensor  communis  tendons  at 
the  lower  end  of  the  radius.  This  marks  the  site 
of  the  radiocarpal  articulation.  When  this  fills  with 
fluid  the  depression  is  replaced  by  a  fluctuating  swell- 
ing, and  in  case  of  doubt  a  needle  can  be  inserted 
here  and  the  contents  of  the  joint  aspirated  for  diag- 
nostic purposes.  This  site  is  particularly  indicated  in 
doubtful  cases,  since,  the  original  infection  being  upon 
the  palmar  side,  there  is  not  great  danger  of  infecting 
the  joint  if  it  is  not  already  involved. 

FoREAEM  Involvement  with  Secondary  Hemorrhage 

One  of  the  most  serious  complications  met  with  in 
the   later   stages   of   forearm   involvement   is   that   of 


I'D  REARM  INVOLVEMENT  IV  mi  UEMORRUAQE       401 

lu'inorrhagi'.  Tlu-  ousel  of  a  sudden,  profuse  hemor- 
rhage in  a  patient  who  is  unable  to  care  for  himself  in 
the  temporary  absence  of  attendants  may  lead  to  an 
immediate  lethal  issue.  The  condition  is  especially 
dreaded,  since  the  surgeon  looks  ujjon  the  condition  as 
most  difficult  to  handle,  since  he  fears  to  undertake  the 
dissection  which  he  believes  to  be  necessary  to  find  the 
point  of  hemorrhage  and  ligate.  He  therefore  tempo- 
rizes with  a  bandaging  of  the  arm  and  tamponade, 
only  to  be  subjected  to  greater  anxiety  on  account  of 
a  subsequent  hemorrhage.  It  would  seem  that  this 
complication  may  be  successfully  dealt  with  if  the 
surgeon   will  only  have  in   mind   the  following  facts. 

1.  The  vessel  nearly  always  at  fault  is  the  ulnar. 

2.  The  surgeon  should  not  temporize,  but  cut  down 
upon  and  ligate  at  once  the  bleeding  vessel. 

The  reason  for  the  involvement  of  the  ulnar  vessel 
is  seen  by  examining  the  cross-sections  (Figs.  53  to  57, 
and  107),  in  which  it  is  shown  that  the  pus  early  involves 
this  vessel.  The  line  of  extension  is  along  this  vessel, 
both  up  toward  the  elbow  and  dow^nward  to  the  ulnar 
side  of  the  forearm.  The  radial  is  well  separated  from 
the  space  in  a  majority  of  cases. 

M\  statements  do  not  depend  alone  upon  my 
anatomical  and  experimental  studies.  Clinical  proof 
in  support  of  it  can  be  adduced  from  m^'  experience, 
and  also  from  numerous  cases  reported  in  the  literature. 
I  will  let  two  cases  suffice  for  that:  one  that  came  under 
my  observation,  and  one  from  the  service  of  Prof. 
Yelpeau  in  which  a  postmortem  was  performed.  This 
latter  is  added  for  the  further  reason  that  the  post- 
mortem serves  to  give  further  corroboration  to  my 
statements  as  to  the  position  of  pus  in  these  cases, 
a  fact  which  cannot  be  defmitely  proved  except  b\' 

postmortem.     M\'  own  case  I  shall  report  briefly. 
26 


402  FOREARM  INVOLVEMENT 

Case  XLIV.— Mr.  H.  Referred  to  Dr.  Richter  at 
the  Post-Graduate  Hospital,  with  whom  I  saw  the 
patient  in  consultation. 

Ten  days  previous  to  the  onset  of  the  first  hemor- 
rhage the  patient  had  suffered  from  a  tendon-sheath 
infection  of  the  ulnar  and  radial  bursae,  with  extension 
into  the  forearm.  The  infection  had  not  been  opened 
promptly,  and  even  after  the  primary  incisions  the 
drainage  from  the  forearm  had  not  been  satisfactory. 
Dr.  Richter  had  made  free  drainage,  but  by  that  time 
the  vitality  of  the  vessel  had  been  impaired.  A  sudden 
profuse  hemorrhage  occurred,  which  jeopardized  the 
patient's  life  before  it  was  discovered  by  the  nurse. 
A  constrictor  about  the  arm  and  tamponade  completely 
controlled  the  hemorrhage,  and  it  was  felt  that  it 
would  not  recur.  However,  two  days  later  a  second 
profuse  hemorrhage  occurred,  and  the  ulnar  vessel  was 
cut  down  upon  as  soon  as  the  patient  had  recovered 
from  the  severe  shock.  The  source  was  found  to  be 
the  ulnar,  as  had  been  prognosticated.  It  was  ligated 
with  catgut,  and  the  patient  made  an  uneventful  re- 
covery.    Function  in  the  hand,  however,  was  impaired. 

The  history  of  the  following  case,  made  the  more 
interesting  by  the  personal  attention  of  the  eminent 
Prof.  Velpeau,  serves  further  to  emphasize  the  possi- 
bility of  hemorrhage  from  ulceration  of  the  ulnar 
vessel.  The  presence  of  the  fistulous  tracts  near  the 
annular  ligament  suggested  the  necrosis  of  the  carpal 
bones  which  was  present,  and  the  deep  position  of  the 
pus  in  the  forearm  is  worthy  of  note.  The  whole 
clinical  picture  was  one  of  extensive  involvement  of 
the  wrist-joint,  deep  phlegmon  of  the  arm,  and  the 
infection  of  synovial  sheaths  which  at  a  later  day 
would  in  all  probability  have  been  relieved  by  opera- 
tive procedure. 


FOREARM  INVOLVEMENT  WITH  HEMORRHAGE      403 

Case  XLV  (Bauchet).— Whitlow  of  the  left  thumb 
caused  by  a  prick  of  a  needle;  multiple  abscesses  pro- 
duced by  the  spread  along  the  synovial  sheath  to  the 
wrist  and  forearm.  Hospital  gangrene  complicating 
the  abscesses  of  the  wrist  and  following  the  tissues 
along  the  ulnar  artery,  severe  hemorrhage,  tamponade, 
tourniquet;  gangrene  of  hand  and  forearm ;  amputation ; 
danger  of  hospital  gangrene  in  stump.     Recovery. 

Patient,  aged  fifty  years,  in  the  service  of  M.  Velpeau, 
Charity  Hospital;  sick  for  two  and  one-half  months; 
entered  April  25,  1851;  was  dismissed  August  13. 

About  two  and  one-half  months  ago  the  patient 
pricked  the  thumb  of  his  left  hand  with  a  needle.  There 
resulted  a  phlegmon  of  this  finger  which  extended 
rapidl}^  over  the  whole  hand;  abscesses  formed  on  the 
palmar  aspect  of  the  finger  and  hand,  some  of  which 
opened  simultaneously  and  some  of  which  were  opened 
by  a  bistoury;  the  swelling  persisted,  and  even  spread 
through  the  entire  thickness  of  the  wrist  and  forearm, 
along  the  synovial  sheath. 

On  the  palmar  face  of  the  wrist  one  notes  several 
sinus  openings  from  which  passes  a  purulent  fluid, 
viscid,  clear,  and  thready;  b}'  pressing  the  palmar 
surface  from  below  up,  one  causes  this  liquid  to  flow 
back.  These  openings  seem  to  communicate  freely 
with  the  synovial  sheaths  of  the  flexor  tendons  of  the 
fingers  at  the  level  of  the  wrist. 

The  inflammation  spreading  from  the  hand  to  the 
forearm  along  these  channels  is  very  intense,  and  pre- 
sents the  characteristics  of  a  diffuse  phlegmon.  During 
the  next  seven  weeks  the  patient  was  treated  in  an 
expectant  manner. 

June  20.  Appearance  of  hospital  gangrene.  The  open- 
ings on  the  palmar  aspect  of  the  wrist  are  larger,  puffed 
up,  mushroom-like,  and  forming  a  large  projection 
showing  a  spongy,  fungous,  grayish  aspect. 


404  FOREARM  INVOLVEMENT 

June  28.  Growth  of  the  wound,  which  now  covers 
the  whole  palmar  face  of  the  wrist.  Sinking  of  the 
mushroom-like  elevation  of  flesh.  All  the  tissues  be- 
tween the  skin  and  the  bones  of  the  wrist  are  in  a 
state  of  putrilage,  and  the  flexor  tendons  are  floating 
in  this  decomposed  matter.  These  tendons  are  stripped 
of  their  sheath,  exfoliated,  and  have  lost  their  silvery 
appearance. 

June  29.  During  the  preceding  night  considerable 
hemorrhage  from  the  ulnar  artery. 

After  several  days  hospital  gangrene  developed  in  the 
hand,  and  Prof.  Velpeau  amputated  at  the  upper  third 
of  the  forearm.   The  patient  then  made  a  rapid  recovery. 

Pathological  anatomy  of  the  amputated  member.  A 
careful  dissection  permits  one  to  ascertain  that  the 
ulceration  involves  only  the  ulnar  artery;  the  central 
end  of  this  artery  is  stopped  by  a  blood  clot.  The 
radial  artery  in  the  gangrenous  portion  is  filled  with 
fibrinous  clots. 

Upon  examining  the  other  tissues,  one  notes  at  the 
level  of  the  focus  of  the  palmar  abscess  purulent  trails 
which  ascend  the  length  of  the  forearm  in  the  tendi- 
nous grooves,  and  the  length  of  the  aponeurotic  sheaths 
of  the  muscles  of  the  anterior  aspect  of  the  forearm, 
to  the  level  at  which  the  forearm  was  amputated. 
One  notes,  moreover,  an  infiltration  of  purulent  fluid 
between  these  grooves  and  these  aponeurotic  sheaths. 
The  connective  tissue  of  the  forearm  is  all  infiltrated 
like  lard.  All  the  tissues  of  the  hand  are  completely 
sphacelated,  dead,  and  black. 

From  all  the  evidence,  therefore,  one  is  justified  in 
assuming  that  in  the  ordinary  case  the  hemorrhage 
arises  from  the  ulnar  artery,  and  proceeding  after 
the  manner  suggested  below  when  dealing  with  this 
complication. 


CHAPTER    XXVII 

TREATMENT   OF    INVOLVEMENT   OF   THE 

FOREARM    SECONDARY    TO    HAND 

INFECTIONS 

TREATMENT  OF  UNCOMPLICATED  CASES 

The  treatment  of  the  subcutaneous  abscesses  sec- 
ondary to  lymphangitis  has  been  discussed  in  Chapter 
XXIII. 

In  deaHng  with  the  deep  forearm  involvement,  two 
methods  may  be  used:  (i)  The  older  procedures  by 
which  the  incision  which  opened  the  ulnar  bursa  may 
be  continued  upward  into  the  forearm,  cutting  the 
anterior  annular  ligament  (see  p.  261  for  full  descrip- 
tion of  this  method).  This  procedure,  however,  I 
personall}^  have  abandoned  except  in  rare  cases.  (2) 
Follow^ing  the  anatomical  studies  described  in  previous 
chapters,  I  have  used  lateral  incisions  upon  either  side 
above  the  wrist  (Fig.  iii).  In  many  cases  only  one 
has  been  used,  that  upon  the  ulnar  side.  By  referring 
to  the  cross-sections  and  Figs.  106  and  107,  the  site 
of  these  incisions  may  be  seen.  I  begin  my  incision 
about  an  inch  above  the  styloid  process  of  the  ulna 
and  carry  it  upward  for  about  three  inches,  cutting 
down  to  the  ulna  on  a  level  ^vith  its  volar  surface.  The 
attachment  of  the  deep  fascia  to  the  bone  is  separated 
and  then  the  finger  is  inserted  between  the  tendons  and 
the  pronator  quadratus.  A  free  opening  is  secured. 
If  it  is  deemed  wise  to  make  a  second  incision  upon  the 
radial  side,  an  artery  forceps  is  passed  across  from  the 
ulnar  side  (Fig.  112).    The  forceps  should  hug  the  radius 


406 


INVOLVEMENT  OF  THE  FOREARM 


closely,  and  when  the  point  impinges  upon  the  skin  of 
the  radial  side  an  incision  is  made  through  the  skin 
for  a  distance  of  a  couple  of  inches.     The  opening  is 


Fig.  Ill 


Lines  represent  the  various  incisions  made  for  drainage  of  the  infected 
tendon  sheaths  and  their  possible  extensions  into  the  forearm.  (See  text 
for  complete  description.) 

enlarged  by  separating  the  fascial  attachment  with  the 
fingers.  Any  pockets  between  the  tendons  or  muscles 
are  widely  opened  by  the  palpating  finger. 


Fig.  112 


m.n.     r.a. 


Cross-section  7  cm.  above  radial  styloid.  Artery  forceps  inserted  trans- 
versely in  juxtaposition  to  ulna  and  radius  through  the  anterior  interosseous 
space,  showing  that  incision  can  be  made  here  and  not  injure  important 
vessels  and  nerves.  Notice  tissue  between  radial  artery  and  the  forceps: 
r.  a.,  radial  artery;  u.  a.,  ulnar  artery;  u.  n.,  ulnar  nerve;  m.  n.,  median 
nerve. 

If  the  case  has  been  opened  late  and  the  pus  has 
infiltrated  the  forearm  extensively,  I  commonly  add 
an  incision  at  a  second  site  higher  up,  about  the  middle 


TREATMENT  OF  UNCOMPLICATED  CASES  407 


Fig.  113 


Cross-section  of  forearm  at  about  its  middle.  The  knife  is  seen  to  make 
an  incision  be3^ond  the  flexor  carpi  ulnaris  and  the  flexor  profundus,  which 
incision  should  be  made  for  pus  in  the  middle  of  the  forearm.  (See  Fig.  114-) 
Cotton  packed  in  the  opposing  surface  shows  the  position  of  pus. 


Fig.  114 


Photographs  showing  the  proper  incisions  for  draining  abscesses  in  fore- 
arm. The  photograph  above  is  made  of  a  cadaver  arm  in  which  serial  sections 
were  made  and  the  proper  sites  for  striking  large  cavities  determined,  the 
artery  forceps  being  thrust  through  immediately  above  the  wrist,  and  an 
ulnar  incision  being  made  at  the  middle  of  the  forearm.  The  photograph 
below  shows  the  sites  of  these  two  ulnar  incisions. 


408 


INVOLVEMENT  OF  THE  FOREARM 


of  the  forearm.  Here  one  will  see  by  examining  the 
cross-section  (Figs.  109  and  113)  the  pus  tends  to  lie 
between  the  flexor  carpi  ulnaris  and  the  flexor  sublimis 
around  the  ulnar  artery  and  nerve.  Therefore  an  inci- 
sion is  made  about  one  inch  from  the  ulna  on  the  flexor 
surface  of  the  forearm,  attempting  to  strike  the  area 
between   these  two  muscular  bodies   (Figs.    113,    114, 

Fig. 115 


Photograph  of  a  hand  of  a  patient  showing  proper  incisions  for  opening 
tendon-sheath  infections  of  the  thumb  and  Httle  finger,  with  ulnar  bursal 
extensions  of  pus  in  the  forearm.  This-  patient  made  a  complete  recovery 
with  function  and  left  the  hospital  at  the  end  of  one  month.  Function  was 
complete  at  the  end  of  three  months. 


and  115).  The  opening  is  separated  widely  by  the 
forceps  and  fingers  after  the  skin  incision  is  made. 
Instead  of  this,  one  may  cut  down  directly  upon  the 
flexor  surface  of  the  ulna  and  separate  the  fibrous 
attachment  of  the  flexor  carpi  ulnaris  from  this  bone, 
and  in  this  manner  separate  the  muscle  from  the  flexor 
sublimis  and  profundus  and  thus  drain  the  pockets. 


TRKATMKNT  OF  UNCOMPLICATED  CASES  409 

Tliese  arc  all  I  he  incisions  ihal  in  niy  experience  have 
been  necessar>'  U)  pnxJucc  rajjid  cure  in  these  cases.    One 

Fig.  ii6 


Photograph  of  baby  G.'s  hand  and  forearm  three  days  after  incision  was 
made  for  the  drainage'of  anulnar  bursal  infection  with  extension  into  the 
forearm.     (See  Case  XLVI.) 

Fig.  117 


Result  three  months  after  (baby  G.),  showing  extension  and  flexion  of 
fingers.  Perfect  function  restored  except  for  two  distal  phalanges  of  the 
little  finger. 

should  use  care  not  to  cut  through  any  muscular  body, 
since  drainage  will  be  unsatisfactory.     The  incisions 


410  TNVOLVEMENT  OF  THE  FOREARM 

should  be  free  and  may  be  kept  open  from  twenty-four 
to  forty-eight  hours  by  gutta-percha  strips  or  vaseline 
saturated  gauze.  Even  in  very  young  individuals  this 
treatment  is  most  satisfactory.  My  youngest  case  of 
ulnar  bursitis  and  forearm  involvement  was  in  a  child 
(Case  XLVI,  Figs.  ii6  and  117,  p.  409),  whose  photo- 
graph I  here  present. 

Case  XLVI. — Wesley  Hospital.  The  child  was  three 
months  old  when  it  was  treated  and  six  months  old 
when  the  second  photographs  were  taken.  There  was 
absolutely  no  impairment  of  function -in  any  of  the 
joints  or  muscles  except  the  little  finger,  in  which  it 
lost  the  power  of  flexion,  as  will  be  seen  by  examining 
the  photographs.  Owing  to  the  age  of  the  patient  and 
the  severity  of  the  infection,  the  life  of  the  patient  was 
despaired  of  by  the  family  physician.  The  child  left 
the  hospital  at  the  end  of  the  eighth  day  after  the 
incision  described  above  had  been  made. 


TREATMENT  IN  CASES  WHERE  THE  WRIST-JOINT  IS 
INVOLVED 

Besides  the  incisions  suggested  above  for  drainage 
of  the  forearm,  especial  considerations  must  be  borne 
in  mind  when  dealing  with  involvements  of  the  carpal, 
carpometacarpal,  or  carporadial  articulations.  Owing 
to  the  frequently  associated  involvement  of  the  radial 
bursa,  this  will  generally  have  been  opened,  and  in 
serious  cases  the  necrotic  tendon  will  have  been  re- 
moved. The  fact  that  when  this  occurs  the  patient 
is  generally  of  advanced  age  will  emphasize  the  neces- 
sity of  radical  treatment  rather  than  temporizing 
measures  which  might  be  justifiable  in  younger  indi- 
viduals. This  holds  true  not  alone  for  the  resection 
of  the  tendon,  but  also  as  regards  removal  of  the  carpal 
bones.      In   every  one  of  the  several   cases  reported 


CyiSES  JrilERE  THE  IfRIST-JOINT  IS  fNrOfJTJ)     411 

above,  in  which  the  joint  became  iinolved,  a  resection 
of  some  or  all  the  carpal  bones  was  indicated.  Even 
in  younger  individuals,  unless  prompt  and  radical 
incisions  are  made,  associated  with  careful  after- 
treatment,  unfortunate  sequels  are  likely  to  result. 
That  it  does  not  always  ensue  I  am  convinced  by  two 
cases  which  came  under  my  observation,  in  which  the 
joint  made  a  recovery  without  necrosis  of  the  bones,  but 
here  prompt  drainage  had  been  instituted.  However, 
I  cannot  speak  with  authority  upon  this  point,  since, 
fortunately,  my  own  experience  with  this  serious 
sequela  has  been  limited.  A  study  of  the  anatomy 
suggests  the  cause  of  the  tenacity  of  this  infection  and 
the  rapidity  with  which  it  involves  the  entire  joint. 
We  note  that,  as  described  by  Gray,^  while  there  are 
four  separate  synovial  sheaths,  yet  in  reality  the  joint 
proper  has  only  two,  and,  moreover,  these  two  are  so 
intimately  associated  that  the  least  erosive  action  on 
the  part  of  an  infection  lying  in  one  would  cause  an 
extension  to  the  other.  Moreover,  the  removal  of  any 
of  the  more  important  carpal  bones  in  the  radiocarpal 
articulation  will  permit  of  immediate  extension  in  the 
synovial  spaces  about  the  distal  bones,  as,  for  instance, 

1  Although  all  the  authors  agree  in  describing  the  radiocarpal  synovial  sac 
as  isolated  from  the  carpal,  there  is  great  variation  in  the  description  of  the 
carpal  sacs.  Cunningham  and  Quain  follow  Allen  Thompson,  and,  in  addition 
to  the  radiocarpal  and  cuneiform-pisiform,  describe  one  sac  between  the  semi- 
lunar and  cuneiform  above  and  the  os  magnum  and  unciform  below,  another 
between  the  scaphoid  above  the  trapezium  and  trapezoid  below,  these  being 
separated  from  the  carpometacarpal  sac  below,  with  a  single  sac  between  the 
trapezium  and  thumb  metacarpal.  Gerrish  follows  Testut,  giving  the  same 
description  with  the  exception  that  he  divides  the  carpometacarpal  between 
the  middle  and  ring  metacarpals  into  two.  Joessel,  on  the  other  hand,  shows 
a  communication  between  the  carpal  and  the  metacarpocarpal  on  the  radial 
side,  with  a  separate  sac  for  the  metacarpocarpal  of  the  ring  and  little  finger 
metacarpals.  Gray  shows  a  general  communication  between  the  carpal  and 
metacarpocarpal.  This  difference  of  opinion  simply  demonstrates  that  the 
communications  vary  in  different  individuals.  In  a  surgical  consideration 
we  should  expect  a  more  or  less  free  communication,  consequently  in  this 
discussion  I  have  followed  Gray's  classification. 


412  INVOLVEMENT  OF  THE  FOREARM 

in  Case  XXX  we  read:  "Resected  proximal  line  of 
carpal  bones,  later  distal  row  of  carpal  bones  sloughed." 
Consequently,  in  those  cases  where  the  infection  is 
confined  to  the  radiocarpal  articulation  we  should 
attempt  to  remove  the  carious  bone  by  the  curette  and 
give  perfect  drainage  to  the  joint,  with  the  hope  of 
preventing  extension  to  the  carpal  synovial  sac.  The 
probable  involvement  of  the  radio-ulnar  synovial  sac 
should  be  borne  in  mind,  since  it  seems  to  be  a  frequent 
complication.  The  intimate  relation  of  the  ulnar 
sheath,  as  already  pointed  out,  results  in  early  and  ex- 
tensive involvement  of  the  os  magnum  (Fig.   io8). 

Where  the  carpal  synovial  sheath  is  involved,  how- 
ever, we  may  remove  any  of  the  carpal  bones  with  the 
exception  of  the  cuneiform,  semilunar,  or  scaphoid 
without  danger  of  causing  a  spread  to  the  radiocarpal 
joint. 

The  infection  of  the  synovial  sheath  between  the 
pisiform  and  cuneiform  may  spread  to  the  carpal  arti- 
culation, as  in  Case  XLII.  In  relation  to  which  Forssell 
quotes  from  Henle  to  the  effect  that  anatomically  there 
is  frequently  a  communication  between  the  two  sheaths. 

In  no  case  of  involvement  of  the  wrist-joint,  in  which 
the  diagnosis  was  delayed  three  weeks,  did  the  patient 
escape  without  the  removal  of  some  of  the  bones  of 
the  joint.  In  other  words,  there  was  considerable 
erosion  of  the  bones  before  the  diagnosis  was  made. 
We  are  urged,  therefore,  to  watch  with  especial  care 
aged  patients  with  involvement  of  the  radial  bursa  and 
to  open  the  joint  at  the  first  evidence  of  infection.  I 
am  convinced,  however,  that  this  complication  should 
be  a  rare  one  in  those  cases  submitted  to  early  and 
radical  treatment  for  infections  of  tendon  sheaths  and 
soft  parts.  Early  in  the  course  of  joint  involvement 
free  incision  will  give  great  possibility  of  a  cure  without 
the  necessity  for  resection.     But  should  the  indication 


TREATMENT  IN  CASES  OF  SECONDARY  HEMORRHAGE     AV.\ 

arise  for  curcUagc  or  rcnioxal  of  llic  carpal  bones,  it 
should  be  done  thoroiighh  and  (^oni|)l('t('l\  aloni^^  the 
lines  suggested  above. 

TREATiMENT  IN  CASES  OF  SECONDARY  HEMORRHAGE 

As  has  already  been  hinted  in  dealing  with  this  sub- 
ject, those  cases  showing  hemorrhage  should  not  be 
temporized  with.  As  soon  as  the  patient  has  recovered 
from  the  primary  shock  and  before  the  temporary 
tamponade  and  constriction  have  been  removed,  the 
surgeon  should  make  an  incision  over  the  ulnar  vessel. 
To  do  this  an  incision  should  be  made  about  the  middle 
of  the  forearm  on  the  ulnar  side,  as  described  above. 
The  fiexor  carpi  ulnaris  is  then  drawn  to  the  ulnar 
side  and  the  artery  searched  for  (see  Fig.  iii).  The 
site  of  the  hemorrhage  should  be  sought  and  the 
vessel  double  ligated  proximally  and  distally.  Tam- 
ponade and  clotting  cannot  lie  dejocnded  upon.  Fur- 
ther hemorrhages  are  almost  sure  to  occur  and  leave 
the  patient  in  such  serious  condition  that  he  ma>'  not 
survive  the  combined  hemorrhage  and  infection. 


CHAPTER    XXVIII 
SEQUELS  OF  INFECTIONS  OF  THE  HAND 

CHRONIC  PROCESSES,  OSTEOMYELITIS,  ARTHRITIS, 
CONTRACTURES,  AND  ATROPHY 

In  cases  showing  a  long-continued  suppuration,  we 
ask  ourselves  what  structures  are  involved  which  pro- 
long the  trouble,  or  why  we  have  inefficient  drainage. 
Frequently  both  factors  are  at  work.  By  far  the  most 
frequent  causes  are  osteomyelitis,  arthritis,  and  necrosis 
of  tendons. 

Areas  which  were  primarily  poorly  drained  cavities 
are  soon  complicated  by  one  of  these  factors.  Suppura- 
tive arthritis  seldom  exists  without  concomitant  osteo- 
myelitis. Such  cases  frequently  give  a  history  of 
primary  tenosynovitis,  followed  by  osteomyelitis,  end- 
ing in  arthritis. 

Involvement  of  the  wrist-joint  has  been  discussed  in 
the  previous  chapter. 

The  pathology  of  these  cases  naturally  varies  with 
the  tendency  of  the  tissues  to  react  to  the  particular 
germ  which  is  the  exciting  cause,  the  length  of  time  the 
process  has  existed,  and  the  structure  involved. 
Grossly  the  most  important  findings  are  the  sinuses, 
which  are  an  almost  constant  accompaniment  of  chronic 
disease.  Here  we  note  several  types,  and  while  there 
is  a  distinct  difference  between  them,  any  system  of 
classification  is  inadequate.  We  might  say  the  osseous 
and  connective-tissue  types,  or  the  acute,  subacute, 
and  chronic.  While  the  pathology  presents  some 
justification  for  either  system,  yet  the  reactive  resist- 


INVOLVEMENT  OV  THE  FINGER  PROPER  415 

ancc  of  the  individual  and  the  kind  of  ^erni  enter  into 
the  subject  as  varying  factors;  consequently  only 
generalized  statements  can  be  made. 

The  chronic  osseous  type  presents  three  i)ictures, 
varying  with  the  bones  involved:  (i)  Those  cases  where 
the  terminal  phalanx  is  the  seat  of  osseous  destruction; 
(2)  where  the  finger  proper  is  involved;  (3)  where  the 
metacarpals  and  carpal  bones  are  involved. 

INVOLVEMENT  OF  THE  FINGER  PROPER 

Those  cases  (first  group)  showing  chronic  processes 
in  the  terminal  phalanx  have  already  been  discussed 
in  the  chapter  on  Felons  (Chapter  II), 

The  second  group  of  cases  noted  in  the  chronic 
osseous  type  is  that  which  comprises  suppurative  pro- 
cesses of  the  proximal  and  middle  phalanges.  We  all 
have  had  opportunity  to  observe  that  the  proximal 
interphalangeal  joint  particularly  may  become  involved 
early,  either  primarily  or  secondarily.  In  the  case  of 
the  metacarpophalangeal-joint,  however,  there  is  more 
fibrous  tissue  intervening  between  the  tendon  sheath 
and  the  joint  and  the  adjoining  bone;  therefore,  the 
sheath  erodes  through  at  some  less  resistant  point,  as, 
for  instance,  at  the  proximal  interphalangeal  joint,  in 
the  course  of  the  tendon  oyer  the  proximal  phalanx, 
or  at  its  proximal  end  in  the  palm  of  the  hand.  Fre- 
quently I  have  seen  a  sinus  lead  from  the  proximal 
end  of  the  sheath  of  a  tendon  through  the  palmar  fascia, 
and  the  metacarpophalangeal  joint  still  remain  intact 
(Fig.  108).  Again,  the  metacarpophalangeal  joint  is 
likely  to  escape  in  cases  of  palmar  abscesses  where  the 
diaphysis  of  the  metacarpal  has  become  involved,  or 
even  when  the  process  has  been  so  severe  as  to  extend 
under  the  annular  ligament  and  invade  the  carpal 
articulation.     It  has  been  my  experience  in  these  cases 


416 


SEQUELS  OF  INFECTIONS  OF  THE  HAND 


that  the  distal  articulation  frequently  escapes  even  in 
long-continued  synovial  disease  and  extensive  osteo- 
myelitis. 

In  the  ordinary  case  of  chronic  suppuration  in 
the  finger  it  is  the  proximal  interphalangeal  joint 
that  is  at  fault,  and  the  pathological  condition  noted 
in  Fig.  119  is  fairly  typical.  The  constant  irritating 
discharge  coming  from  the  necrosing  bone,  passing 
through    the    connective    tissue    rich    in   lymphatics, 

Fig.  118 


In  this  case  the  metacarpophalangeal  joint  was  intact,  although  the 
tendon  sheath  was  involved  and  a  sinus  had  opened  at  its  proximal  end 
through  the  palmar  fascia,  all  of  the  distal  and  part  of  the  middle  phalanx 
had  been  lost  and  the  proximal  interphalangeal  joint  was  extensively  destroyed. 


produces  an  excessive  deposit  of  granulation  tissue, 
building  up  a  small  volcano-like  structure,  from  which 
oozes  forth  a  constant  stream  of  pus,  and  through 
which  winds  a  tortuous  canal  leading  down  to  the 
necrotic  bone.  Where  bone  alone  is  involved,  I  have 
seen  this  crater  clearly  defined,  occupying  no  greater 
extent  than  the  length  of  one  phalanx  and  raised  above 
the  surface  for  a  distance  half  the  diameter  of  the  finger. 
This  characteristic  picture,  however,  is  seldom  seen, 
owing  to  the  very  frequent  involvement  of  the  tendon 


INVOLVEMENT  OF  THE  FINGER  FROPFR 


417 


or   the   joint   in    the   same   j)rocess.      Here,    while    the 
development  of  granulation  tissue  is  still  excessive,  the 


I'  ii;.  1 19 


PP 


a 


Drawing  from  pathological  section,  showing  sinus  leading  down  to  carious 
bone.  An  associated  tenosynovitis  has  increased  the  extent  of  the  granula- 
tion tissue  and  destroyed  in  part  the  typical  volcano-like  picture  of  an  un- 
complicated palmar  bone  sinus. 

I'^iG.  120 


Uncomplicated  bone  sinus  on  dorsum  of  phalanx. 


mouth  of  the  crater  is  generally  much  wider,  owing  to 

the  excessive  discharge  from  the  tendon  sheath.     The 

granulation   tissue   is  not  so  circumscribed,   although 
27 


418  SEQUELS  OF  INFECTIONS  OF  THE  HAND 

very  abundant.  Moreover,  the  picture  loses  some  of  its 
force,  owing  to  the  associated  swelHng  of  the  finger 
along  the  tendon  sheath,  the  absence  of  which  in  the 
first  case  serves  to  accentuate  the  local  tumor  forma- 
tion. Again,  if  the  sinus  be  upon  the  dorsum  there  is 
less  granulation  formation,  owing  both  to  the  smaller 
amount  of  connective  tissue  and  probably  also  to  the 
great  reduction  in  the  number  of  lymphatics  (Fig.  120). 

Fig.  121 


Cross-section  through  the  joint,  showing  head  of  the  proximal  phalanx. 
Notice  the  large  amount  of  tissue  between  the  tendon  and  the  joint  cavity 
as  compared  to  Fig.  122. 

It  is  not  necessary  to  go  into  the  minute  pathology 
of  osseous  necrosis,  since  that  process  is  well  known 
and  described  in  the  ordinary  text-books.  However,  a 
few  details  peculiar  to  these  two  phalanges  should  be 
mentioned.  We  so  often  see  three  processes  in  con- 
junction, so  that  it  is  difficult  to  say  in  what  sequence 
they  developed  —  namely,  tenosynovitis,  arthritis  of 
the  proximal  interphalangeal  joint,  and  necrosis  of  the 
middle  phalanx.  The  cross-sections  here  presented 
(Figs.  121  and  122)  demonstrate  the  close  proximity 
of  the  tendon  sheath  to  the  bone  and  joint  respectively. 


INVOLVEMENT  OF  THE  FINGER  PROPER  119 

From  the  character  of  the  tissue  it  would  seem  reason- 
able to  assume  that  first  the  joint  is  involved,  and  the 
phalanx  sequentially.  In  the  few  early  cases  that  I 
have  been  able  to  observe  discriminatingly,  the  joint 
seemed  to  have  the  more  extensive  involvement  of 
the  two.  However,  if  that  be  true,  w^hy  does  the  middle 
phalanx  suffer  so  much  more  than  the  proximal  one, 
a  fact  which  I  have  had  the  opportunity  to  verify 
frequently.      Is  it   that   the  point  of  invasion   is   the 

Fig.  122 


Cross-seclion  through  the  epiphysis  of  the  middle  phalanx.  Notice  the 
loose  mesh  and  the  small  amount  of  connective  tissue  between  the  tendon 
and  the  bone. 

epiphysis  of  the  middle  phalanx?  Does  the  fact  that 
that  phalanx  only  has  an  epiphysis  articulating  with 
the  joint  have  any  bearing  on  the  subject?  This  ques- 
tion must  be  left  for  further  study. 

Again,  destruction  of  the  epiphysis  is  frequently 
noted,  w^hile  the  diaphysis  is  only  partly  involved 
(Fig.  119).  The  anatomical  relation  of  the  sheath  of 
the  tendon  to  the  joint  capsule  and  the  epiphysis  may 
help  to  explain  this,  but  it  is  possible  that  the  vascular 
nature  of  the  epiphyseal  tissue  may  have  considerable 


420 


SEQUELS  OF  INFECTIONS  OF  THE  HAND 


bearing,  since  the  involvement  may  have  its  origin 
through  the  blood  supply  rather  than  by  direct  erosion. 
That  isolated  destruction  of  a  diaphysis  of  a  phalanx 
may  occur  at  times  cannot  be  questioned,  and  a  study 
of  the  cross-sections  demonstrates  how  easily  this  can 
occur  if  the  tendon  sheath  be  eroded. 

What  we  most  often  find  upon  operation  in  these 
cases  is  a  suppurative  arthritis  with  extensive  destruc- 
tion of  both  the  epiphysis  and  shaft  of  the  middle 
phalanx,  while  the  proximal  surface  of  the  joint,  that 
is,  the  head  of  the   proximal   phalanx,   may  be  only 

Fig.  123 


Drawing  from  a  pathological  specimen,  showing  destruction  of  the  epiphysis 
of  the  middle  phalanx,  with  pinhead-sized  areas  of  the  necrosis  on  the  head 
of  the  proximal  phalanx. 


slightly  or  not  at  all  eroded  (Fig.  123);  at  least,  the 
articular  surface  is  still  clear  and  shining,  with  possibly 
one  or  two  minute  foci  of  destruction.  Frequently  it 
has  shown  a  larger  area  of  necrosis  upon  the  shaft 
just  at  the  point  where  the  ligaments  of  the  joint  are 
attached.  Indeed,  at  times,  either  upon  the  volar  or 
dorsal  surface,  varying  with  the  site  of  the  original 
infection,  I  have  scooped  out  at  this  site  an  area  the 
size  of  a  small  pea,  the  articular  surface  apparently 
being  free,  while  the  epiphysis  of  the  middle  phalanx 
was  almost  entirely  destroyed. 


INVOLVEMENT  OV  THE  VINCER  PROl'ER  -121 

IklOAIMIiN'r.  Ill  (lie  chioiiic  processes  iiixolxiiiu,  llit- 
liiii^er  i)i()j)er,  llie  diagnosis  iniisl  \)c  made  lirsl  as  to  llie 
strucUirc  invoKcd.  If  the  Lcndon  siiealli,  it  niiist  l)e 
opened  throughout  its  extent  to  give  perfect  drainage. 
Frequently  it  will  be  necessary  to  remove  the  tendon 
in  these  chronic  cases.  The  possibility  of  localized 
involvement  must  always  be  borne  in  mind.  In  these 
cases  a  plastic  exudate  forms  and  prevents  extension 
along  a  sheath;  here  only  so  much  of  the  sheath  as 
has  been  involved  should  be  exposed.  If  the  joint  be 
invaded,  some  judgment  is  called  for,  since  in  the  very 
earliest  stages  it  may  recover  with  partial  restoration 
of  function  if  the  infection  is  a  mild  one,  the  joint 
surfaces  not  destroyed,  and  other  structures  which 
might  prolong  the  suppuration  are  uninvolved.  In  a 
great  majority  of  the  cases,  however,  considerable 
destruction  of  the  proximal  phalanx  will  have  taken 
place  when  the  case  comes  to  operation,  and  the  ques- 
tion arises  whether  an  amputation  should  be  advised. 
Certain  sociological  factors  come  into  consideration. 
If  the  patient  be  a  laboring  man,  with  a  family  de- 
pendent upon  him,  and  at  examination  we  find  an  ex- 
tensive destruction  of  the  joint  with  a  tenosynovitis, 
amputation  offers  the  quickest  method  of  giving  a 
serviceable  hand.  If,  however,  the  patient  desires  to 
preserve  the  finger,  in  a  majority  of  the  cases  one  can 
be  assured  that  the  finger  may  be  preserved,  but  that 
it  will  be  somewhat  shortened.  Exceptionally  the 
finger  ma>'  be  preserved  with  considerable  function. 
In  certain  cases  it  becomes  imperative  to  make  the 
attempt,  as,  for  instance,  in  infections  of  the  thumb. 
This  member  is  so  valuable  that  some  sacrifice  is  justi- 
fiable in  the  attempt  to  preserve  it.  In  Case  XLVII, 
quoted  below,  the  articular  surfaces  and  a  considerable 
portion  of  the  shaft  of  the  proximal  phalanx  were 
removed.     There  was  no  involvement  of  the  tendon 


422 


SEQUELS  OF  INFECTIONS  OF  THE  HAND 


sheath.  A  fairly  serviceable  opposing  member  was 
thus  saved  to  the  hand. 

Case  XLVI I. —Primary  paronychia  of  thumb,  sec- 
ondary suppurative  arthritis  of  interphalangeal  joint, 
resection,  ultimate  recovery,  with  preservation  of  the 
thumb. 

C.  H.,  treated  in  the  Northwestern  University 
Medical  School  Dispensary,  May,  1902.  Infection 
began  on  the  thumb  under  the  nail  at  the  side  and 
developed  into  a  typical  "run-around."  When  he 
applied  at  the  dispensary,  four  weeks  after  the  begin- 


FiG.  124 


Photograph  showing  thumb  in  which  joint  has  been  resected.  Notice 
the  opposing  ability  of  the  member.  (Case  XLVII,  Hamilton,  reported 
above.) 

ning  of  the  infection,  a  chronic  suppurative  arthritis 
had  developed,  involving  the  interphalangeal  joint. 
Under  narcosis  the  epiphysis  of  the  distal  phalanx  and 
about  half  of  the  distal  portion  of  the  proximal  phalanx 
were  found  partially  destroyed.  All  this  involved  bone 
was  removed  with  a  curette,  the  nail  was  removed, 
silkworm-gut  drain  inserted,  hot  boric  dressings  applied. 
The  tendon  sheath  of  the  flexor  longus  pollicis  was  not 
involved.  The  patient  returned  repeatedly  for  dress- 
ings, and  after  four  weeks  all  discharge  ceased.  The 
patient  was  discharged  with  the  thumb  shortened  half 


INVOLVEMENT  OF  THE  FINCER  PROPER 


423 


an    inrh,    with    ability    to    flex   the  distal    i)lialanx   20 
degrees,  complete  function  in  the  metacarpophalangeal 


Fig.  125 


A  photograph  of  a  finger  with  a  chronic  suppurative  arthritis  of  the  middle 
metacarpophalangeal  joint,  dressed  in  extension  produced  by  an  ordinary- 
rubber  band  attached  to  the  end  of  the  finger  by  means  of  a  string  tied  to 
it  and  the  ends  fastened  through  the  eyes  of  a  button,  the  latter  being  attached 
to  the  finger  by  narrow  adhesive  strips  running  around  the  finger  up  to  the 
middle  metacarpophalangeal  joint — a  gauze  roller  around  the  adhesive 
strips.  Extension  is  secured  by  fastening  the  rubber  band  on  the  back  by 
a  piece  of  adhesive  plaster,  as  shown  in  Fig.  126.  The  board  splint  on  the 
palmar  surface  is  prevented  from  being  displaced  up  the  arm  or  laterally 
by  adhesive  strips  as  shown  in  the  figures.  It  is  a  modified  Buck's  extension. 
The  relief  from  discomfort  and  rapid  recovery  under  its  use  is  often  remark- 
able. 

joint.  There  was  little  strength  to  the  flexion  of  the 
distal  phalanx,  but  it  served  admirably  as  an  opposing 
member  when  using  the  fingers  (Fig.  124). 

Fig.  126.     (See  Fig.  125) 


The  procedure  when  the  proximal  interphalangeal 
joint  of  the  fingers  is  involved  is  as  follows:  Owing  to 
the  frequent  destruction  of  the  proximal  end  of  the 
middle  phalanx,  this  is  chosen  for  attack,  and  the  entire 


424  SEQUELJE  OF  INFECT tONS  OF  THE  HAND 

epiphysis  and  generally  about  half  of  the  shaft  is  re- 
moved. If  the  articular  surface  of  the  proximal  phalanx 
is  intact,  it  is  not  disturbed,  otherwise  this  may  be  re- 
moved also,  my  desire  being  in  the  first  place  to  remove 
all  necrotic  bone,  and  secondly  to  separate  the  ends  of 
the  bone  so  far  that  only  a  fibrous  union  will  take  place, 
thus  allowing  some  motion  at  this  joint  if  the  tendon 
is  intact.  Otherwise  no  motion  can  be  promised.  These 
fingers  are  dressed  in  slight  flexion,  so  that  if  no  func- 
tion results  they  will  not  be  in  the  way  and  will  still 
be  of  some  use,  at  least  for  cosmetic  purposes.  In  some 
cases  I  have  tried,  with  moderate  success,  a  variety  of 
extension  on  a  straight  splint.  The  proximal  end  is 
fastened  at  the  wrist,  and  at  the  distal  end,  adhesive 
straps  are  fastened  to  the  end  of  the  splint  and  the 
distal  portion  of  the  finger,  so  that  the  ends  of  the 
necrotic  bones  are  separated.  The  'details  of  this 
mechanical  contrivance  may  be  seen  by  examining 
Figs.  125  and  126.  This  aids  in  preserving  the  func- 
tionating joint,  although  it  is  somewhat  difficult  to 
retain  in  position.  Not  much  can  be  promised  in  the 
way  of  function  in  a  majority  of  cases.  That  in  excep- 
tional cases  these  fingers  can  be  saved  with  a  moderate 
amount  of  function,  even  in  some  cases  of  combined 
suppurative  arthritis  and  tenosynovitis,  is  demon- 
strated by  Case  XLVIII. 

Case  XLVIII. — Limited  tenosynovitis  of  index 
finger,  arthritis  of  proximal  interphalangeal  joint,  osteo- 
myelitis of  middle  phalanx,  resection  of  phalanx, 
recovery,  with  preservation  of  the  finger  and  slight 
motion  at  the  joint. 

Miss  C.  W.  Seen  in  consultation  with  Dr.  C.  E. 
Boddiger.  Infection  had  ,  begun  in  the  index  finger 
by  a  prick  of  a  needle  while  sewing  two  weeks  pre- 
viously, and  the  soft  parts  had  been  opened  over  the 
middle  phalanx. 


IMOI.I  r.MEM  OF  I'llE  I  I  Mil:  R  PROPER  425 

('oiidilioii  n/M>n  lixdiuiiinlioii .  Sui)|)iii'ali\  c  If'iio- 
syii()\  ill's  of  (he  index  tendon  extending  to  llie  nieta- 
carp(jphaicUigeal  articulation,  but  no  farther.  Tendon 
exposed.  Suppurative  arthritis  of  the  proximal  inter- 
phalangeal  joint,  with  destruction  of  the  j^roximal  end 
of  the  middle  phalanx.  Distal  phalanx  ncjt  involved, 
articular  surface  slightly  clouded,  but  not  eroded. 

Operation. — Tendon  sheath  opened  throughout  ex- 
tent of  infected  area.  Middle  phalanx  resected  to 
one-half  its  extent.  Dorsal  counterincision  made  at 
side  for  thorough  drainage,  and  hot  boric  dressings 
applied. 

Course. — After  three  weeks,  the  finger  had  entirely 
healed;  fiexion  at  metacarpophalangeal  and  distal 
phalangeal  joints  perfect;  flexion  at  proximal  inter- 
phalangeal  joint  15  degrees.  Six  months  after  oyx^r^.- 
tion  atrophy  of  soft  tissues  of  distal  and  middle  pha- 
langes. The  patient  states  that  the  finger  is  not  of 
great  service,  but,  on  the  other  hand,  is  not  in  the  way, 
and  she  is  very  glad,  for  cosmetic  reasons,  that  it  was 
saved. 

Where  there  is  only  a  destruction  of  the  synovial 
covering  of  the  joint,  resection  is  not  indicated.  It  is 
probable  that  a  functionating  joint  can  be  restored  in 
case  of  ankylosis  if  the  tendon  sheath  is  not  invoh'ed, 
although  I  have  not  had  the  opportunity'  to  demon- 
strate it.  If  the  destruction  of  the  adhesions  by  re- 
peated flexion  of  the  finger  by  passive  motion,  which 
I  have  used  with  more  or  less  success  at  various  times, 
does  not  succeed,  the  implantation  of  periosteum  from 
the  tibia,  as  suggested  by  Hofil'man,^  is  worthy  of  con- 
sideration, or  the  transplantation  of  a  pad  of  tissue 
and  fat  may  be  used  with  satisfaction. 

Suppuration    is    uncommon    in    the    metacarpopha- 

'  Arch.  f.  klin.  Chir.,  vol.  Ixxx,  No.  2,  p.  31 1 ;  Zur  Behandlung  der  knachemen 
Ankylose  im  Elbogengelenk. 


426  SEQUELS  OF  INFECTIONS  OF  THE  HAND 

langeal  joint,  but  here  also  resection  may  be  resorted 
to  if  the  tendon  is  intact.  If  this  be  involved,  in  a 
majority  of  cases,  I,  myself,  at  the  present  time  would 
amputate  the  finger. 


INVOLVEMENT  OF  THE  HAND  PROPER  AND  THE  META- 
CARPALS AND  CARPALS 

Pathology. — The  third  type  of  chronic  osseous 
lesion  is  that  in  which  the  bones  of  the  hand  proper 
are  involved.  Here,  unless  modified  by  an  original 
wound  or  operative  procedure,  the  picture  is  again 
different,  owing  to  the  dense  aponeurosis  upon  the 
palmar  side  and  the  sheet  of  dense  tissue  upon  the 
dorsum  uniting  the  tendons  of  the  extensor  communis 
digitorum.  These  dense  sheets,  particularly  upon  the 
palm,  prevent  the  free  egress  of  pus,  and,  as  a  conse- 
quence, it  is  more  likely  to  burrow  a  considerable  dis- 
tance from  the  site  of  origin  before  exit  (Fig.  127). 
This  diffuses  the  reactive  inflammation,  and  even  if 
the  exit  is  found  near  the  site,  the  dense  sheet  prevents 
the  crater-like  elevation  of  granulation  tissue  noted 
in  the  second  or  phalangeal  type.  Hence,  we  are  more 
likely  to  find  a  diffuse  swelling  of  the  whole  palm  or 
dorsum  with  multiple  ostia,  any  of  which  may  be  open 
for  a  time  and  discharge,  while  another  may  be  closed. 
There  is  often  only  a  small  amount  of  granulation 
tissue  about  the  openings.  In  these  cases  of  early 
osseous  involvement  often  no  sinus  will  appear  upon 
the  palmar  surface,  unless  the  soft  tissues  of  the  palm 
have  been  seriously  involved  primarily,  or  the  infection 
has  spread  into  the  wrist- joint,  and  this  is  generally 
preceded  by  palmar  phlegmon  or  tenosynovitis.  There- 
fore, in  these  cases  of  osteomyelitis  of  the  metacarpal 
bones  dorsal  sinuses  are  most  common.  They  may 
appear  at  any  point  on  the  dorsum,  but  have  a  pre- 


INVOLVEMENT  OF  THE  HAM)  /'ROPER 


427 


dilectioii  for  the  sides  and  distal  part  iicai-  the  knuckles 
(Fig.  128),  owing  to  the  dense  sheet  of  tissue  before 
mentioned.  It  is  a  well-known  fact,  however,  that 
frequently  this  sheet  has  areas  where  it  is  not  complete, 
particularly  in  the  lower  third  between  the  tendons; 
and  through  these  pus  may  discharge.     But  it  is  not 


Fig.  127 


Blood  vfnnels. 


Skin. 


Lionhrical   muscle  hi 
middle  palmar  space. 


Pidiniir  arch. 

Blood  vessel. 

Lumlirical  muscle 

and   tendon. 

Median  nerve  and  vessels. 

Flexor  longus  pollicis. 

TJienar  muscles. 


1/  pns. 


usseons  muscle 
•ead  over  bone. 


■sis  of  bone, 
aneous  space, 
iponeurotic  space. 

e. 

erox.'iei  .separated 
hy  .fa.sciat  septum. 
Extensor  communis 

tendon. 

Middle  palmar  space 
'  filled  with  pus. 

^l-in. 
Metacarpals. 


Eadial  artery. 


Drawing  showing  the  relation  of  pus  in  the  middle  palmar  space  to  the 
tendons.  Also  showing  course  pus  pursues  in  its  course  along  the  lumbrical 
muscle  to  point  on  the  dorsum  near  the  web.  Serial  sections  of  the  hand 
were  made  as  shown,  the  tissues  teased  out,  and  middle  palmar  space  filled 
with  plaster  of  Paris.  Sections  restored  to  normal  position  and  sagittal 
section  made  between  ring  and  middle  metacarpal  of  all  sections  except 
the  proximal.    Heavy  dotted  area  shows  position  pus  would  occupy. 


at  all  an  uncommon  thing  to  see  a  sinus  ostium  at  either 
side  over  the  index  and  little  finger  metacarpal,  and  one 
or  two  at  the  distal  end  between  the  knuckles,  from 
a  single  focus  of  infection  in  either  the  middle  or  ring 
metacarpal  (Fig.  64),  as  will  be  shown  clearly  by  .v-ray 
picture.      Again,    these   ostia   on    the   dorsum   at   the 


428 


sequelje  of  infections  of  the  hand 


knuckles  may  be  due  to  a  chronic  procCvSS  in  the  pahii 
discharging  through  the  lumbrical  canals  (see  Fig.  127). 


FLP 


Schematic  drawing,  showing  pus  under  dorsal  aponeurosis  with  ostium 
at  the  side:  PF,  palmar  fascia;  MPS,  middle  palmar  space;  LM,  lumbrical 
muscle;  FLP,  flexor  longus  poUicis;  TS,  thenar  space;  ITS,  indefinite  thenar 
space;  IDS  AS,  infected  dorsal  subaponeurotic  space;  DSCS,  dorsal  subcuta- 
neous space;  OM,  osteitis  of  the  metacarpal;  DP  A,  deep  palmar  arch;  C,  site 
of  discharge  of  pus. 

So   far   as    I    have    observed,    there   is   no   peculiar 
pathological  destruction  of    the  metacarpal  bones  in 

Fig.  129 


Drawing  of  fragments  of  metacarpal  removed  by  Dr.  W.  E.  Schroeder. 

these  cases  (Fig.  129).    There  is  one  clinical  fact,  how- 
ever,  worth  remembering  from  a  therapeutic  stand- 


i.M  (J f.r /■:.]!/■: XT  or  the  ii/Ixd  proper  429 

poinl,  and  that  is  tlic  rclatixc  ininiiini(\  Ironi  iiuoKc- 
nient  of  (ho  nu'tarai'i)()i")halanp,cal  joint  ;  tliis  is  possibh' 
owing  to  the  dense  ligaments  surrounding  the  joint, 
which  i)rotect  it  from  invasion  by  way  of  the  synovial 
sheath  and  adjacent  phlegmons.  As  a  consequence  of 
this  we  are  often  able  to  preserve  a  functionating  finger, 
although  a  considerable  destruction  of  tlie  metacarpal 
may  be  present;  isolated  necrosis  of  a  metacarpal  is 
uncommon  except  in  tuberculosis  or  syphilis. 

Involvement  of  the  wrist-joint  in  chronic  processes 
is  characterized  by  multiple  foci  on  both  the  dorsal 
and  palmar  surface. 

I  append '  the  .v-ra>-  photograph  of  the  hand  of  S. 
(Fig.   130). 

Case  XLIX. — S.,  Post-Graduate  Hospital,  Decem- 
ber, 1910.  The  jiatient  suffered  from  a  previous  tendon- 
sheath  infection  of  the  ulnar  and  radial  sheaths.  I 
saw  him  after  three  months  of  chronic  infection,  when 
there  were  multiple  sinuses  both  on  the  dorsum  and 
flexor  surface  of  the  wrist  from  the  joint,  with  lateral 
and  distal  sinuses  upon  the  dorsum  (A  the  hand  from 
osteom^-elitis  of  the  metacarpals  of  the  index,  middle, 
and  little  fingers.  There  was  no  involvement  of  the 
metacarpophalangeal  articulations,  in  spite  of  the  long- 
continued  infection  and  extensive  osteomyelitis.  The 
x-YQ.y  picture  clearly  showed  the  location  of  the  foci. 
All  of  the  carpal  bones  were  removed  and  the  necrotic 
part  of  the  metacarpals.  The  hand  rapidly  recovered. 
All  discharge  ceased  within  four  weeks.  Almost  all 
function  was  lost.  I  ha\'(^  been  surprised  to  find  that 
now  after  three  months  he  is  developing  some  fiexion 
of  the  fingers  and  hand,  so  that  he  can  now  hold  a 
glass  and  perform  other  gross  functions  with  the  hand. 

The  following  histor\-  of  a  jiatieiil  in  the  practice  of 
Dr.  H.  B.  Baumgarth,  with  w  lioiii' 1   s.iw    the  case  in 


Fig.  130 


X-ray  photograph  of  hand  (patient  S.,  see  Case  XLIX).  Necrotic  bone 
was  removed  from  the  wrist  and  the  three  metacarpals.  Sufficient  function 
was  recovered  to  grasp  gross  objects.  Thirty  degrees  of  flexion  of  fingers  at 
present,  and  function  is  growing  better. 


IMOLl'EMENT  OF  THE  II.IM)  I' ROPER  431 

consultation,  illustrates  the  course  of  these  chronic 
cases  when  untreated. 

Case  L. — Chronic  infected  process.  Middle  pahiiar 
abscess,  later  involving:  the  ulnar  bursa,  associated  with 
sinuses  along  the  lumbrical  canals.  Case  untreated 
surgically. 

Mrs.  G.,  diabetic,  received  infection  September  5, 
1904,  at  web  between  the  middle  and  ring  fingers. 
The  patient  consulted  a  magnetic  healer  and  remained 
under  his  care  for  seven  weeks,  when  she  applied  to 
Dr.  Baumgarth,  who  obtained  the  following  history 
and  drained  the  hand  properly.  Twenty-one  days  after 
the  receipt  of  the  infection,  point  2,  noticed  on  the 
dorsum,  opened  up;  a  few  days  later,  points  3  and  4 
opened,  slightly  more  on  the  dorsal  surface  than  on  the 
palmar.  Points  5,  6,  7,  and  8  appeared  successively 
in  the  next  few  days.  After  an  interval  of  a  few  days, 
points  9  and  10  appeared,  followed  in  succession  by 
12  and  13,  and  after  an  interval  of  several  days,  14, 
15,  and  16,  at  which  time  the  patient  applied  to  Dr. 
Baijmgarth,  who  thoroughly  drained  the  pockets,  and 
the  patient  made  a  tardy  recovery.  The  atrophy  of 
the  distal  phalanx  of  the  index  finger  is  due  to  a  pre- 
vious felon.  The  atroph}^  of  the  other  fingers  followed 
as  a  sequence  of  the  present  infection. 

On  February  25  adhesions  were  broken  up  under 
nitrous  oxide,  which  benefited  the  movement  of  the 
finger  and  wrist  to  a  slight  extent  only. 

A  careful  study  of  this  case  serves  to  point  out  the 
pathological  sequence  which  occurred  as  a  result  of  the 
infection  (Fig.  131).  Points  i  and  2  were  the  original 
site  of  the  infection,  which  spread  from  there,  without 
doubt  by  lymphatic  extension  or  continuity  of  tissue, 
along  the  lumbrical  canal  into  the  midpalmar  space; 
from  here  in  turn  it  retraced  its  course  through  the 


432 


SEQUELS  OF  INFECTIONS  OF  THE  HAND 


lumbrical  canals  to  the  base  of  the  index  finger,  point  4, 
and  the  base  of  the  Httle  finger,  point  6.  The  ulnar 
bursa  evidently  became  involved,  and  points  9  and  10 
show  the  site  of  rupture  from  the  sheath,  the  other 
areas  at  the  base  of  the  palm  developing  as  a  rupture 
of  the  proximal  end  of  this  bursa.  This  point  was 
corroborated  by  Dr.  Baumgarth  at  the  time  of  opera- 

FiG.  131 


Photograph  of  Dr.  Baumgarth's  case.  Figure  numbers  on  the  photograph 
represent  the  various  sinuses  and  their  approximate  order  of  development 
by  which  the  course  of  the  infection  can  be  traced.     (See  Case  L.) 


tion,  since  pus  was  found  above  the  annular  ligament 
in  this  synovial  sac.  It  is  to  be  noted  that  all  the 
primary  points  of  rupture  from  i  to  8  appeared  upon 
the  dorsal  surface  of  the  base  of  the  webs  of  the  fingers. 
The  characteristic  claw  hand  seen  in  neglected  tendon- 
sheath  infection  is  shown  in  Fig.  132. 

In   those   exceptional   cases   in   which   the   pus   has 


-u 


I\rOIJ-KMi:\T  OF  Tim  I/.tXD  PROPER 


A'''' 
'too 


extended  to  the  dorsum  between  the  metacarpal  bones, 
there  is  generally  some  destruction  of  ]:)onc  r((|uirinj? 
attention.  It  is  at  times  seen  in  a(l\anced  cases 
accompanying  wrist-joint  invasion. 

Treatment  of  Cases  Involving  the  Hand  Proper. 
— The  treatment  in  those  cases  in  which  the  chnjnic 
process  lies  in  the  palm  may  be  confusing.  We  should 
determine  first  the  location  of  the  pus.  Does  it  lie  in 
the  synovial  sheaths  or  in  the  fascial  space?    Are  the 

Fig.  132 


Photograph  showing  claw  hand  in  neglected  tendon-sheath  infection. 


bones  or  the  wrist-joint  involved?  While  theoreticalh- 
difficult  to  determine,  it  is  not  so  confusing  as  in  the 
acute  cases,  since  there  arc  generally  sinuses  which  can 
be  follow^ed  down  to  the  hidden  pockets.  .Y-ray  photo- 
graphs may  show  necrotic  bone.  Complete  anesthesia 
is  essential.  No  operation  upon  infected  hands  should 
be  begun  without  it.  The  ramifications  should  be 
followed  up  carefully  and  with  patience.  I  shall  not 
speak  in  detail  of  the  factors  which  lead  us  to  diag- 

28 


434  SEQUELS  OF  INFECTIONS  OF  THE  HAND 

nosticate  the  presence  of  pus  in  the  various  sites, 
since  this  has  already  been  discussed  exhaustively  in 
the  previous  chapters. 

Various  sinuses  leading  from  the  tendons  to  the  sur- 
face will  be  followed  down  to  the  respective  synovial 
sheaths.  The  sinuses  found  at  the  most  proximal 
point  of  the  finger  sheaths  designate  the  corresponding 
sheath,  and  this  should  be  cut  down  upon  and  followed 
distally  along  the  finger  until  every  part  of  the  tendon 
bathed  in  pus  is  exposed.  Where  the  little  finger 
tendon  is  involved,  the  extension  of  the  sheath  in  the 
palm  should  be  borne  in  mind,  and  the  opening  con- 
tinued proximally  over  this  when  the  grooved  director 
inserted  into  the  infected  sheath  on  the  little  finger 
passes  up  into  this  without  obstruction.  Here  the 
sheath  should  be  opened  throughout  its  extent  up  to 
the  annular  ligament,  the  incision  lying  to  the  ulnar 
side  of  the  tendons.  The  incision  should  be  limited  to 
the  annular  ligament  until  the  decision  has  been  made 
as  to  whether  the  infection  has  extended  under  this 
into  the  proximal  end  of  the  sheath  above  the  annular 
ligament.  If  this  is  diagnosticated,  the  ligament  should 
be  cut  and  the  incision  be  continued  into  the  forearm 
as  far  as  the  upper  end  of  the  sheath.  Instead  of  this 
last  incision  the  upper  end  of  the  sheath  may  be  drained 
by  incisions  upon  the  ulnar  and  radial  side  of  the 
forearm  as  described  in  the  chapter  on  Forearm  In- 
volvement. It  is  not  wise  to  open  the  sheath  above 
and  below  the  ligament  and  leave  this  latter  intact. 
Having  thoroughly  opened  this,  the  question  then 
arises:  Has  the  radial  bursa,  i.  e.,  the  sheath  of  the 
flexor  longus  poUicis,  become  involved?  If  so,  this  must 
be  opened  throughout  its  extent  down  to  a  thumb's 
breadth,  distal  to  the  annular  ligament.  The  incision 
should  stop  here  for  fear  of  injuring  the  motor  nerve 
to  the  thenar  area. 


INVOLVEMENT  OF  THE  HAM)  PROPER  435 

If  the  tendons  have  become  necrotic,  removal  is 
indicated;  on  (he  oilier  hand,  oik-  is  often  surprised  at 
the  amount  (^f  vitality  present  in  the  tendons  which 
have  lost  their  synovial  covering,  therefore  after  open- 
ing a  sheath  considerable  conservatism  is  justifiable 
when  it  comes  to  a  question  of  preserving  or  removing 
a  tendon.  Some  of  the  chronic  sluggish  processes  in 
the  fingers  have  seemed  to  be  benefited  by  the  Klapp 
suction  cup  (Fig.  133). 

Fig.  133 


Showing  Klapp's  aspiration  cup  used  in  some  old  chronic  infections  of  the 

fingers. 

If  the  fascial  spaces  are  involved,  they  should  be 
drained  after  the  methods  described  in  Chapter  XVII. 

In  considering  the  treatment  of  those  cases  in  which 
the  suppurating  ostia  appear  upon  the  dorsum,  par- 
ticularly between  the  knuckles,  I  have  already  pointed 
out  that  in  a  majority  of  cases  these  are  really  sinuses 
leading  from  the  palm  along  the  lumbrical  canals 
(Fig.  127),  and  the  perfect  drainage  of  the  palm  along 
the  lumbrical  canals,  as  already  mentioned,  will  end 
in  rapid  recovery  if  uncomplicated  by  tendon  or  bone 
involvement. 

If  the  bones  of  the  hand  or  wrist  are  involved,  they 
should  be  removed  or  the  necrotic  part  curetted  out. 


436  SEQUELS  OF  INFECTIONS  OF  THE  HAND 

In  treating  the  wrist-joint  the  general  principles  as  to 
the  removal  of  bones,  which  have  been  enunciated  in 
Chapter  XXVII,  when  dealing  with  carpal  involve- 
ment, should  be  borne  in  mind.  These  should  not, 
however,  interfere  with  the  paramount  rule  that  all 
dead  bone  should  be  removed. 


ATROPHY  AND  CONTRACTURE 

The  anatomical  and  clinical  evidence  already  ad- 
duced shows  the  tendency  for  the  infection  to  extend 
in  juxtaposition  to  the  bloodvessels  and  nerves.  The 
former  leads  to  contracture  about  the  veins  and  lym- 
phatics, and  consequently  a  persisting  distal  edema. 
The  most  serious  sequelae,  however,  ensue  because  of 
the  extension  along  the  nerves — metacarpal,  ulnar,  and 
median — leading  secondarily  to  trophic  changes  in  the 
part.  This  secondary  change  follows  probably  upon 
contraction  of  the  scar  tissue  about  the  nerves,  since 
they  are  not  likely  to  be  destroyed  by  the  process. 
At  times  we  see  the  median  nerve  persisting,  partly 
isolated  from  the  surrounding  tissue,  although  in 
conjunction  with  the  tendons  it  may  be  destroyed  at 
the  wrist-joint  from  pressure  necrosis  by  the  non- 
distensible  annular  ligament. 

This  secondary  change  is  particularly  noticeable  in 
the  atrophy  of  the  distal  phalanges,  and  even  of  the 
whole  hand  (Figs.  131  and  132).  This  sequela  of  nutri- 
tive and  trophic  disturbance  yields  slowly  or  not  at 
all  to  the  restorative  processes  of  nature.  Massage, 
passive  motion,  and  constant  use  of  the  hand  carried  out 
systematically  under  the  careful  personal  supervision 
of  the  surgeon  may  aid  nature.  Adhesions  between  the 
joints,  when  they  are  not  the  result  of  the  destruction 
of  the  synovial  coverings,  may  be  treated  by  repeated 
non-violent   passive   movements   under   nitrous   oxide 


CIIROMC  IMI'.CTIOXS  487 

aiu'stlu'sia,  oi'  1)\  (he  \aiious  a|)|)liaii(  is  dcsiLiiicd  lo 
l)r(Kluc('  passixc  molioii,  particularK-  tlmsc  wliidi  ad 
by  exhaustint;  llu'  air,  and  hciui-,  in  addition  lo  pro- 
ducing mobility,  favor  active  congestion  of  the  parts 
(Figs.  85  and  86,  p.  280).  In  case  of  neglected  tendon - 
sheath  infection  one  expects  to  see  the  characteristic 
claw  hand.  Experimental  investigations  as  U)  the 
restoration  of  destroyed  tendons  have  been  carried 
out,  but  as  yet  nothing  definite  can  be  recommended 
in  cases  of  loss  of  finger  tendons,  although  something 
may  be  hoped  for  in  the  future.  Experience  has  taught 
me  that  scientifically  made  incisions  based  upon  the 
anatom}^  I  have  pointed  out  will  provide  complete 
drainage  of  all  the  pockets  and  in  the  end  will  give 
a  much  more  serviceable  hand  than  we  have  had  the 
fortune  to  secure  in  the  past.  It  cannot  be  urged  too 
strongly  that  we  should  make  careful  stud}'  as  to  the 
possible  position  of  pus  in  the  hand,  to  the  end  that  we 
may  make  early  and  radical  incisions  and  thus  prevent 
these  cases  of  atrophy  and  contracture. 

RESUME— CHRONIC   INFECTION'S 

Necrosis  of  the  distal  phalanx  ordinarily  ends  in 
sloughing  of  the  diaphysis  alone.  Joint  function  should 
be  preserved.  Incision  should  be  made  laterally  in- 
stead of  upon  the  volar  surface  (see  Chapter  I). 

The  proximal  interphalangeal  joint  is  most  conmionK" 
involved.  The  proximal  i)halanx  escapes  while  the 
epij)hysis  and  part  of  the  diaph\sis  of  the  middle- 
phalanx  are  destroyed. 

Conservative  operations  ma>-  be  done  with  some 
success. 

Isolated  involvement  of  the  tendon  sheaths  ma\'  be 
present.  Incision  of  the  sheath  should  expose  all 
invoKed  i)arts. 


438  SEQUELS  OF  INFECTIONS  OF  THE  HAND 

Chronic  palmar  abscesses  frequently  point  on  the 
dorsum,  passing  along  the  lumbrical  canals.  Palmar 
abscesses  may  be  opened  along  these  canals. 

Chronic  dorsal  abscesses  may  point  at  a  distance 
from  the  focus,  owing  to  the  dorsal  aponeurotic  sheet. 

The  carpal  joints  are  frequently  invaded  from  the 
radial  bursa;  abscesses  and  sinuses  appear  upon  the 
dorsum,  as  well  as  upon  the  flexor  surface.  Every 
effort  should  be  made  to  preserve  the  integrity  of  the 
tissue  between  the  first  and  second  row  of  carpal 
bones.     (See  Chapter  XXVII.) 

Serious  forearm  abscesses  lie  dorsal  to  the  flexor 
profundus  digitorum,  and  may  be  opened  either  in 
front,  in  connection  with  an  incision  in  the  palm,  or 
by  lateral  drainage. 

Trophic  changes  result  from  the  tendency  of  the 
pus  to  extend  along  the  nerves  and  bloodvessels. 

Complete  function  can  be  promised  patients  suffer- 
ing with  palmar  abscesses  uncomplicated  by  tendon- 
sheath  or  osseous  infection. 

Neglected  tendon-sheath  infections  give  rise  to  the 
claAv  hand.  Tendon-sheath  infections  operated  upon 
early  give  good  function,  except  that  flexion  of  the 
two  distal  phalanges  may  be  lost. 


INDEX 


Abscess,  collar-button,  52 

treatment  of,  55 
in  course  of  lymphatic  vessel,  319 
deep,  of  forearm,  384 
distal  palmar,  52 
of  fascial  spaces,  after-treatment 
of,  296 
treatment  of,  281 
of  forearm,  treatment  of,  405 
localized,  55 

hypothenar  space,  55 
thenar  space,  55 
location  of,  in  forearm,  385 
of   middle   palmar   space,    treat- 
ment of,  282 
periglandular,  treatment  of,  362 
of  radial  lymphatics,  175 
shirt -stud,  52 
subaponeurotic  space,  treatment 

of,  295 
subclavicular  and  shoulder,  treat- 
ment of,  362 
subcutaneous,  in  forearm,  383 
treatment    of,    in   lymphan- 
gitis,  361 
subepithelial,  37 
thenar  space,  treatment  of,  293 
Absorption  of  virulent  toxins,  preven- 
tion of,  251 
Adhesions,  prevention  of,  295 
in  tenosynovitis,  203 

prevention  of,  278 
treatment  of.  Bier's,  280 
Alcohol  dressings,  249 
Anatomy,  cross-section,  distal  to  web, 

84 
one-half  centimeter  proximal 
to  the  joint,  87 
taken  at  wrist,  96 
three      centimeters 

above  joint,  90 
through     base     of 
palm,  94 
distal    part    of 
thenar    emi- 
nence, 93 
epiphysis         of 
proximal 
phalanx,  85 


Anatomy,    cross-section,    two    centi- 
meters above  joint,  88 
of  forearm,  150 

five   centimeters    above 

radial  styloid,  151 
nine  centimeters  above 

radial  styloid,  153 
seven  centimeters  above 

radial  st^doid,  153 
three  centimeters  above 
radial  styloid,  150 
of  forearm  in  relation  to  infec- 
tions, 149 
of  hand  and  forearm,  79 
of  hypothenar  space,  95 
of  lymphatics,  302 
of  middle  palmar  space,  90 
of  thenar  space,  91 
Anesthesia  in  operations,  251 
Annular  Hgament  cut  in  hand  infec- 
tions, 252,  261,  269 
extensions    of    pus    matter, 
177 
Anthrax,  379 
Arthritis,  199,  414,  420 

metacarpophalangeal,  186 
Atrophy,  414,  436 

Axillary    glands,    source    of    involve- 
ment, 320 


B 


Bacillus  aerogenes  capsulatus  infec- 
tion, treatment  of,  378 
of  malignant  edema,  differentia- 
tion of,  377 
Bacteria    of    gas    bacillus    infections, 
differentiation  of,  377 
influence  of  types  of,  in  lymph- 
angitis, 316 
Bier's  hyperemic  treatment,  71,  234, 

251.  277,  353 
treatment  of  adhesions,  280 
Bloodless  field  in  operations,  251 
Bone  involvement,  418 
Bones  of  finger,  treatment  of,  when 
involved,  423 
of  wrist-joint,  necrosis  of,  411 
Bursitis,  radial,  diagnosis  of,  214 


440 


INDEX 


Carbolic  acid  gangrene,  249 
Carbuncles,  38 

anatomical  considerations  of,  38 

pathogenesis  of,  38 

pathology  of,  38 

site  of,  38 

treatment  of,  41 
Carpals,  involvement  and  treatment 

of,  426 
Cautery  to  open  abscesses,  76 
Claw-hand,  203 
Collar-button    abscess,  treatment  of, 

55 
Contractures,  414,  436 
Cross-sections  of  hand  and  forearm. 

See  Anatomy. 


D 


Distal  palmar  abscess,  52 
Diverticula  of  each  of  delinite  spaces, 

115 

Dorsal  abscess,  'diagnosis  of,  223 

as  extension  from  thenar 

space  infection,  183 
from  middle  palmar 
abscess,  182 
subaponeurotic  space,  99 

experimental  study  of 
boundaries  and  posi- 
tion of  secondary 
abscesses  in  case  of 
rupture  from,  142 
subcutaneous  space,  99 

boundaries,    diverticula, 
and   position    of    sec- 
ondary abscess  in  case 
of  rupture  from,   147 
experimental    study    of 
boundaries  and  posi- 
tion     of      secondary 
abscess     in     case     of 
rupture  from,  140 
Dorsum  of  hand  and  forearm,  lymph- 
angitis and,  320 
infections  beginning  in,  194 
tendon  sheaths  of,  112 

infection   of,    treatment 
of,  276 
Drainage  in  incisions  in  forearm,  262 
in  infections,  75 
in  palmar  abscess,  283 
in  tenosynovitis,  251,  276 
at  wrist,  262 
Dressing,  alcohol,  249 

dry,  in  tenosynovitis,  277 
hot  moist,  in  lymphangitis,  351 
in     tenosynovitis,     248, 
277 


Drugs,  antagonistic,  in  lymphangitis, 

356 
Durillon  force,  314 


E 


Edema  of  dorsum,  differentiated  from 
erysipelas,  320 
mistaken  for  pus,  182 
malignant,  378 
in  tenosynovitis,  203 
Embryology    of    hand,    comparative, 

143 

Epitrochlear  glands,  source  of  involve- 
ment, 320 
Er^/sipelas,  373 

differentiated     from     edema     of 
dorsum,  320 
from  lymphangitis,  352 
gangrenous,  373 
treatment  of,  373 
Erysipeloid,  374 
Esmarch  bandage,  321 
Excretion,    stimulation    of,    in   infec- 
tions, 77 
Extensor   carpi   radialis   longior   and 
brevior,  tendon  sheath  of, 
112 
ulnaris,    tendon    sheath    of, 
112 
communis  digitorum,  tendon 

sheath  of,  112 
indicis,  tendon  sheath  of,  112 
longus  poUicis,  tendon  sheath  of, 

112 
minimi  digiti,  tendon  sheath  of, 

112 
ossis  metacarpi    poUicis,    tendon 
sheath  of,  112 


Fascia  palmaris,  isolated  necrosis  of, 

235 

Fascial  spaces,  22,  99 

abscess   of,  acute,  prognosis 
and  resume  of,  297 
'after-treatment  in,  296 
diagnosis  of,  215 
pathogenesis  of,  163 
pathology  of,  196,  198 
surgical     considerations 

of,  163 
symptoms,     signs,     and 
diagnosis  of,  201,  215 
treat mient  of,  281 

immobilization     in, 
29.6 
experiments  as  to  boundaries, 
diverticula,  and  extensions 
from,  143 


INDEX 


441 


I'ascial  spaces,  L'xLcnsicjii  u{,  [nnw  one- 
.  to  another,  177 
]K)sition     ot"     secondary 
abscess  in,  127 
of  forearm,  experimental  in- 
jection of,  154 
infection  of,  63 

direct    implantation    of 
infi'dion     in     spaces, 
169 
etiology  of,  163 
relation  to  lymphanj^itis, 

173.  301 
involvement  of,  168 

recapitulation      as      to 
source  of,  176 
normal  boundaries  of,  127 
relation      of,      to      synoviid 
sheaths,  114 
to  tendon  sheaths,  126 
study    of,    by    serial    cross- 
sections,  83 
Felons,  25 

after-treatment  of,  31 
etiology  of,  25 
pathogenesis  of,  26 
pathology  of,  26 
treatment  of,  29 
Filleaux,  237,  238 
Fillmans,  240 

Finger,  index,  diagnosis  of  extension 
from  infections  beginning 
in,  209 
experimental  study  of  exten- 
sion   after    rupture    from 
tendon  sheath  of,  124 
infection  involving,  185 
tendon  sheath  of,  102 

extensions  from  in- 
fections in,   187 
relation  of,  to  the- 
nar space,  103 
tenosynovitis   of,    treatment 
of,  253 
infectious  processes  of,  415 

course  oflymphatic 

from  each,  320 
extensions  from  primary 

foci  on,  185 
involving  sides  of,  175 
involvement  of,  421 
little,     diagnosis     of     extensions 
from  infections  beginning 
in,  193,  204 
experimental  study  of  exten- 
sion   after    rupture    from 
tendon  sheath  of,  120 
infection  of,  incision  in,  256 
tendon  sheath  of,  105 

relation  of,  to  mid- 
dle palmar  space, 
103 


Finger,  little,  tenosynovitis  of,    treat- 
ment of,  255 
and  ulnar  bursa,  extensions 
from,  treatment  of,  262 
middle,    diagnosis    of    extension 
from  infections  beginning 
in,  191,  209 
experimental  study  of  exten- 
sion   after    rupture    from 
tendon  sheath  of,  117 
extensions     from    tenosyno- 
vitis of,  treatment  of,  255 
tendon  sheath  of,  102 

relation  of,  to  mid- 
dle palmar  space, 
103 
ring,  tliagnosis  of  extensions  from 
infections     beginning     in, 
192,  209 
experimental  study  of  exten- 
sion   after    rupture    from 
tendon  sheath  of,  118 
extensions    from    tenosyno- 
vitis of,  treatment  of,  255 
tendon  sheath  of,  102 

extensions  of,   194 
relation       of,       to 
middle   palmar 
space,  103 
Flexor  longus  pollicis,  tendon  sheath 
of,  104 
tenosynovitis  of,  213 
Forearm,  abscess  of,  deep,  384 
diagnosis  of,  224 
subcutaneous,  383 
treatment  of,  405 
anatomy  of,  79 

in  relation  to  infections,  149 
dissection   and   experimental   in- 
jections of,  159 
incisions  in,  drainage  in,  262 
infections  of,  treatment  of,  263 
injections     of   fascial    spaces  of, 

154 
involvement   of,    abscess   forma- 
tion   without    complica- 
tions, 385 
associated    with    wrist-joint 

invasion,  391 
following     tenosynovitis     of 
tlumib,  treatment  of,  266 
incision  in,  260 
from     infections     of     hand, 
pathology    and    diagnosis 
of,  383 
from  middle   palmar  space, 

177 
secondary   hemorrhage   and, 
400 
treatment  of,  405 
to  little  finger  infection, 
204,  207 


442 


INDEX 


Forearm,  involvement  of,  from  ulnar 
bursitis,  treatment  of,  258 
lymphatics  of,  310 
serial  cross-sections  of,  150 

Forssell,  226,  230 

Friedrich,  241 

Frog-felon,  52 


Gangrene,  carbolic  acid,  249 
Gangrenous  erysipelas,  373 
Gas  bacillus  infection,  375 
Gauze  in  treatment  of  infections,  75 
Gonorrheal  tenosynovitis,  226 
Gutta-percha  in  treatment  of   infec- 
tions, 75 


H 


Hand,  anatomy  of,  79 

chronic    processes    in    palm    of, 

treatment  of,  426 
and  forearm,   lymphatic   vessels 

of,  304 
infections,     diagnosis     of     differ- 
ential, 225 
Heineke,  236 
Helferich,  242 
Hemolysis  in  streptococcus  infections, 

317 

Hemorrhage  in  forearm  mvolvement, 
401 
secondary,  treatment  of,  264,  413 
Hyperemic  treatment.  Bier's,  71,  234, 

251-  277,  353 
Hypothenar  space,  95,  99 

abscess  of,  treatment  of,  281 
anatomy  of,  95 
boundaries,  diverticula,  and 
position  of  secondary  ab- 
scess  in   case   of   rupture 
from,  146 
experimental  study  of  bound- 
aries, diverticula,  and  posi- 
tion of  secondary  abscesses 
in  cases  of  rupture  from, 

H3  .  .      ^ 

infection  of,  diagnosis  of,  233 
relation  of,  to  infection 
inmiddlepalmar 
space,  182 
involvement    of,    source    of, 
176 


Ice  bag  in  axilla  in  treatment  of  in- 
fections, 249 


Immobilization  in  fascial   space   ab- 
scesses, 296 
in  tenosynovitis,  277 
Incision  in  forearm  involvement,  260 
errors  in  making,  261 
in  infections,  prophylactic,  74 
in  little  finger  infections,  256 
in  lymphangitis,  354 
in  tenosynovitis,  251 
in  ulnar  bursal  infections,  256 
Index  finger.     See  Finger,  index. 
Infections.      See   also  Tenosynovitis, 
Lymphangitis,       Fascial- space 
infection, 
carbuncular,  38 
chronic,  repeated,  363 

staphylococcus,  48 
classification  of,  17 
diagnosis  of,  general,  57 
drainage  in,  75 
grave,  57 

passive  hyperemia  in,  71 
simple  localized,  25 
spread  of,  from  any  given  pri- 
mary focus,  185 
from    one    fascial    space    to 

another,  177 
from  sides  of  fingers,   175 
subepithelial,  37 
treatment  of,  Bier's,  71 

boric  acid  solution  in,  72 
cautery  to  open  abscesses  in, 

75 
drainage  in,  75 
drugs  in,  70 
gauze  in,  75 

general  principles  of,  70 
gutta-percha  in,  75 
hot  moist  dressings  in,  72 
Klapp  suction  cup  in,  77 
massage  in,  77 
passive  hyperemia  in,  71 
prophylactic  incision  in,  74 
rest  in,  70 
rubber  tubes  in,  76 
types  of,  17 
Intermediary  palmar  sheath,  anterior, 
no 
posterior,  109 
Interosseous  artery,  anterior,  lymph- 
atic abscesses  and,  175 
Interphalangeal  joint,  proximal,  rela- 
tion of,  to  tendon  sheath,  102 


Joints,  interphalangeal,  210 

proximal,  treatment  of,  when 
involved,  423 
involved,     secondary     to     little 
finger  infection,  204 


INDEX 


443 


Joints,  metacarpophalangeal,  involve- 
ment and  treatment  of,  426 
prcscrvinji  function  of,  in  teno- 
synovitis, 278 


Kakenski,  230 
Kausch,  229 
Klapp,  72,  227,  22 
Konig,  239 


S.  435 


LACUNiE  of  lymphatics,  relation  of,  to 

subcutaneous  abscess,  320,  355 
Lejars,  242 

Leukocytosis,   increase  of  in  lymph- 
angitis, 358 
Lexer,  240 

Little  finger.     See  Finger,  little. 
Lumbrical  muscles,  extension  to  thenar 
space  from  middle  palmar 
space,  182 
involved   from    infection    of 
middle   finger, 
192,  210 
of    tendon    sheath, 

169,  188,  210 
in  web,  193 
from     middle     palmar 

space,  177 
from  ring  finger  tendon 

sheath,  193,  210 
secondary  to  index  teno- 
synovitis,    treat- 
ment of,  253,  254 
to  little  finger  infec- 
tion, 208 
involvement    of,    source    of, 

177 
relations  of,  to  infections  of 
middle  palmar  space,  102, 
172,  254 
tenosynovitis  and,  252 
Lymphangitis,  58 

acute,  simple,  329 

with   minor  local   complica- 
tions, 329 
with  serious  local  complica- 
tions, 330 
with  systemic  involvement, 

333 
bacteria  and,  316 
in    central    part    of    palm,    194, 

195 
complications   of,    treatment   of, 

359 


Lymphangitis,  deep,  334 

differentiated  from  erysipelas,  352 
dressing  in,  351 
drugs  in,  antagonistic,  356 
etiology. of,  314,  325 
extension  of,  in  infection  of  middle 
finger,  192 
of  thumb,  192 
frequency  of  localization  in,  333 
hot  moist  dressings  in,  361 
incision  in,  354 

leukocytosis  in,  increases  of,  358 
pathogenesis  of,  314,  325 
pathology  of,  314,  325 
phlegmonous,  332 
prognosis  of,  347 
relation  of,  to  fascial  space  infec- 
tion, 301 

to  other  types  of  infection, 
301 

to  tenosynovitis,  301 
septicemia  and,  302 
symptoms  and  signs  of,  328 
systemic  involvement  from,  337 
treatment  of,  351 

normal  salt  solution  in,  356 

peptonized  food  in,  356 
types  of,  301,  329 
Lymphatic  abscess  along  arteries,  175 

experimental  injections  and, 

323 
dilatations,  sacciform,  304 
infections,  treatment  of,  351 
rest  in,  353 
Lymphatics,  anatomy  of,  302,  304 

influence    of,    on    course    of 
infection,  318 
course  of,  174 

deep,  312,  322 
fascial  space  infection  and,  173 
history  of,  18 

relation  of,  to  tendon  sheaths,  32 1 
superficial,  304 
termination  of,  311 


M 


Malignant  edema,  378 

Mascagni,  302 

Massage  in   treatment  of  infections, 

77 
Mauclaire,  241 
Median  nerve,  relation  of,  to  bursae, 

io8 
Metacarpal  bones,  extension  of  infec- 
tion of,  to  dorsum,  182 
fifth,  relation  of,  to  infection 

of  hypothenar  space,  172 
involvement  and   treatment 

of,  426 
of  middle  finger,  192 


444 


INDEX 


Metacarpal   bones,    osteomyelitis  of, 

193-   194 

relation   of,  to   infections  of 
middle  palmar  space,  172 
Metacarpophalangeal  arthritis,  186 

joint  and  the  tendon  sheath,  102 
Middle  finger.     See  Finger,  middle, 
palmar  space.    See  Palmar  space, 
middle. 


N 


Necrosis  of  bones  of  wrist,  411 

of  tendons,  197,  266 
Nerves  to  thenar  muscles,  relation  of, 

to  tendon  sheath,  265 
Nicaise,  233,  247 
Normal  salt  solution  in  lymphangitis, 

356 


O 


Oidiomycosis,  45 

diagnosis  of,  47 
Osteomyelitis,  414 

metacarpal  bones,  193,  194 


Palm,  infections  beginning  in,  194 
lymphatics  of,  309 

relation  of,  to  infections,  318 
wound  of,  punctured,  134 
Palmar  abscess,  drainage  in,  283 

fascia,  relation  of,  to  abscesses, 

194 
sheath,  intermediary, anterior,  no 

posterior,  109 
space,  middle,  90,  99 

abscess  of,  treatment  of, 

282 
anatomy  of,  90,  96 
boundaries,   diverticula, 
and  position  of  second- 
ary abscesses  in  case 
of  rupture  from,  144 
experimental    study    of 
boundaries 
and  position 
of  secondary 
abscesses    in 
case  of  ex- 
tension from, 
127 
•of  site  of  rup- 
ture and  ex- 
tensions into 
forearm,  157 


Palmar   space,    middle,    infection    of, 
after  results  of ,  198 
diagnosis  of,  216 
by  direct  implanta- 
tion, 169 
extension  from,  177 
to  thenar  space-, 

181 

to  ulnar  bursas, 

183 

relation  of,  to  hypo- 

thenar  space,  182 

involved  from  infection 

spreading      from 

sides    of    fingers, 

175 
secondary  to  fascial 
space    infec- 
tion, 183 
to  little  finger 
infection, 
208 
to  middle  and 
ring  finger 
tenosyno- 
vitis, 168, 
193.  211 
to    ring   finger 
infection , 
192 
to   tenosyno- 
vitis, treat- 
ment of,  254, 
263 
involvement    of,    source 

of,  176 
and  subaponeurotic 
spaces,   combined  in- 
volvement   of,    treat- 
ment of,  289 
and  thenar  space,  com- 
bined       in- 
volvement 
of,         treat- 
ment of,  285 
interrelation  of, 
96 
Parona,  242 
Paronychia,  31 

pathology  of,  32 
treatment  of,  33 
types  of,  32 
Peptonized  food  in  lymphangitis,  356 
Periglandular  abscess,   treatment  of, 

362 
Phalanges,  distal,  25 

infection  of,  25 
involvement    of    joints    of, 
treatment  of,  253 
Phalanx,  423 

involved  secondary  to  little  finger 
infection,  204 


INDEX 


Phalanx,  niiddk-,  210 

Phlegmon  of   dorsum,   treatment   of, 

361 
Phlegmonous  lymphangitis,  332 
Poiricr,  302 
Poulsen,  245 
Punctured  wound  of  palm,  194 


R 


Radial  artery,  abscesses  along,  175 
bursa,  104 

anatomj'   peculiar   to   infec- 
tions of,  392 
communication     of,     with 

ulnar  bursa,  109 
diagnosis  of  extensions  from 
infections     beginning     in, 
213 
experimental    study    of    site 
of  rupture  and  extension 
into  forearm  from,  155 
infections  of,  extension  of,  U> 
ulnar  bursa,  166 
treatment  of,  265 
involved  secondary  to  little 
finger     infection, 
204,  207 
to  tenosynovitis  of 
throat,  214 
bursitis,  diagnosis  of,  214 
lymphatics,  abscesses  of,  175 
Rheumatism  of  wrist,  225 
Ring  finger.     See  Finger,  ring. 
Rubber  tubes  in  treatment  of  infec- 
tions, 76 
"Run-around"  paronychia,  31 


Sacciform  lymphatic  dilatations,  304 

Sappy, 302 

Scheide,  236 

Schleich,  244 

Schuller,  237,  247 

Septicemia,  337 

Serum     and     vaccine     treatment     in 

lymphangitis,  357 
Shirt-stud  abscess,  52 
Sinuses  in  chronic  processes,  427 

treatment  of,  434 
Sporotrichosis,  322 
Staphylococcic  tenosynovitis,  203 
Streptococcic  tenosynovitis,  203 
Streptococcus     infections,     hemolysis 

in.  317 
Subaponeurotic     space,     abscess     of, 
treatment  of,  295 


Subaponeurotic     space,     boundaries, 

diverticula,  and  position  of 

secondary  abscesses  in  case 

of  rupture  from,  146 

infection  from,  extension  of, 

183 
secondary    changes    fol- 
lowing, 200 
source  of,  173,  183 
treatment  of,  289,  295 
Subcutaneous  abscess  following  radial 
bursal    inflammation, 
treatment  of,  266 
tenosynovitis,    treat- 
ment of,  264 
tissue,  source  of  infection,  173 
Subepithelial  abscess,  37 
Symbiosis,  efTect  of.  on  course  of  infec- 
tion, 317 
Synovial  sacs,  accessory,  109 

sheaths  of  dorsum,  infections  of, 
treatment  of,  276 
fascial   spaces   and,    relation 

between,  1 14 
of  wrist -joint,  41 1 


Tendons,  necrosis  of,  197,  266 
treatment  of,  435 
prevention    of    adhesions    of,    in 

tenosynovitis,  278 
prolapse  at  wrist  prevented  aftei 

incision,  278 
sheaths,  anatomical  distribution 
and  relations  of,  lOl 
upon  dorsum,  112 
extension    to    fascial    spaces 
from,  168 
from  little  finger,  194 
of    extensor    carpi     radialis 
longior   and 
brevior,  1 12 
ulnaris,  112 
communis  digitorum, 

112 
indicis,  112 
longus  poUicis.  112 
minimi  digiti,  112 
ossis  mctacarpi  poUicis, 
112 
to    fascial    spaces,    relations 

of,  126 
of  flexor  longus  pollicis,  104 
experimental 
study  of  ex- 
tension after 
rupture 
from,  125 
surface,  loi 

tendon   of   little   finger, 
105 


446 


INDEX 


Tendon     sheaths     of     index     finger, 

experimental      study      of 

extension    after      rupture 

from,  124 

intercommunication,  of,    109 

of  Uttle  finger,  105 

experimental  study 
of  extension  after 
rupture  from,  120 
of  middle  finger,  experimen- 
tal study  of  ex- 
tension  after 
rupture  from,  117 
infection        involv- 
ing, 192 
of  ring  finger,  experimental 
study    of    extension    after 
rupture  from,  118 
rupture    of,    relation    of,    to 

fascial  spaces,  117 
of  thumb,  anatomical  study 
of    relation     of,     to 
motor  nerves  of  the- 
nar muscles,  265 
spread   of  infection   in- 
volving, 191 
of  thumb,  removal  of,  267 
Tenosynovitis,  59 

acute  suppurative,  treatment  of, 

248_ 
adhesions  in,  203 

prevention  of,  278 
after-treatment  of,  276 

position  of  hand  in,  278 
by  aspiration,  diagnosis  of,  253 
diagnosis  of,  201 
drainage  in,  251,  276 
dressing  in,  dry,  277 

hot  moist,  248,  277 
edema  in,  203 
etiology  of,  163 
extension  of,  from  one  sheath  to 

another,  165 
of  flexor  longus  pollicis,  213 

extension  from,  213 
following  lymphangitis,  treat- 
ment of,  359 
gonorrheal,  226 
incision  in,  251 
of  index  finger,  treatment  of,  251, 

253 
involvement   of  various   sheaths 

in,  164 
of  little  finger,  treatment  of,  255 
lumbrical  space  and,  252 
of  middle  finger,  treatment  of,  251 
relation  of,  to  lymphangitis,  301 
pathogenesis  of,  163 
pathology  of,  196 
preserving  function  of  joints  in, 

278 
prognosis  of,  297 


Tenosynovitis,  relation  of    lymphan- 
gitis to,  301 
of  ring  finger,  treatment  of,  251 
staphylococcic,  203 
streptococcic,  203 
subcutaneous   abscess   following, 

treatment  of,  264 
surgical  considerations  of,  163 
symptoms  and  signs  of,  201 
tenderness  in,  202 
of  thumb,  treatment  of,  248 
treatment  of,  227,  248 

elevation  of  part  in,  249 
immobilization  in,  277 
passive    and    active    move- 
ments in,  278 
rest  in,  249 
Thenar  area,  involved  secondary  to 
index  tenosynovitis,  treatment 
of,  253,  254 
space,  91 

abscess  of,  treatment  of,  293 
anatomy  of,  91,  96 
boundaries,  diverticula,  and 
position  of  secondary  ab- 
scesses in  case  of  rupture 
from,  145 
experimental        study        of 
boundaries    and    position 
of    secondary    abscess    in 
case  of  rupture  from,  133 
infection  of,  diagnosis  of,  216 
extension  of,  to  middle 
palmar  space,  183 
to  other  spaces,  183 
from  tendon  sheath,  188 
involved  from  infection  from 
sides  of  fingers,  175 
from  metacarpophalan- 
geal arthritis,  186 
from     middle     palmar 

space,  181 
secondary       to       index 
finger   tenosyno- 
vitis, 211 
to    tendon    sheath 
infection,  169 
involvement  of,  source  of  ,176 
middle  palmar  abscess  and, 
treatment  of,  285 
space     and,     inter- 
relation of,  96 
Thiersch  graft  after  carbuncles,  45 
Thrombophlebitis,  345 
Thumb,  infection  involving,  191 
tendon  sheath  ot,  104 

extension      of     rupture 
from,  125 
tenosynovitis    of,    treatment    of, 
265 
Toxins,   virulent,    prevention   of   ab- 
sorption of,  251 


INDEX 


447 


U 


Ulnar  artery,  al)scesse.s  along,  175 
hemorrhage  and,  404 
bursa,  105 

communication       of,      with 
radial  bursa,  1 10 
with   tendon   sheath   of 
ring,  middle,  and 
index  finger,  no 
experimental    study    of    site 
of  rupture  and  extension 
into  forearm,  156 
extensions   from,    treatment 

of,  262 
infection  of,  extension  of,  to 
radial  bursa,  166 
incision  in,  257 
involved  from  middle  palmar 
space  infection,  183 
secondary  to  little  finger 
infection,  204 
to  radial  bursal  in- 
fection, diagnosis 
of,  214 
tenosynovitis   of,    treatment 
of,  255 


Ulnar  sheath  infection,  secondary  to 
radial  bursal  inflammation, 
treatment  of,  267 


Von   Volkmann   treatment  of   teno- 
synovitis, 277 


W 


Web  of  finger,  infection  from,  193 
involved  secondary  to  tenosyno- 
vitis, treatment  of,  254 
space,  100 
Wound  of  palm,  punctured,  194 
Wrist-joint,  bones  of,  necrosis  of,  411 
infection  of,  preservation  of  func- 
tion in,  412 
secondary    to    little    finger 
involvement,  204 
involvement  of,  391 
treatment  of,  410 
Wrist,  rheumatism  of,  255 


[^  /'V^  ex.    -  3    "7    t*" 


<  LibrtAKifcb  (nsi.stx) 
RD551  K13  1912C.1 


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2002096870 


